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Iba T, Helms J, Levi M, Levy JH. Thromboinflammation in acute injury: infections, heatstroke, and trauma. J Thromb Haemost 2024; 22:7-22. [PMID: 37541590 DOI: 10.1016/j.jtha.2023.07.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/13/2023] [Accepted: 07/23/2023] [Indexed: 08/06/2023]
Abstract
Tissue microcirculation is essential for the maintenance of organ homeostasis. Following acute infections, activation of coagulation and inflammation, which are critical interconnected responses, lead to thromboinflammation and microthrombosis, thereby contributing to multiorgan dysfunction. Sepsis is the most common underlying disease and has been extensively studied. However, the COVID-19 pandemic further illustrated the pathomechanisms of diseases in which thromboinflammation plays a critical role. During thromboinflammation, injury to monocytes, neutrophils, platelets, and endothelial cells, along with coagulation and complement activation, was further characterized. Thrombin is pivotal in orchestrating thrombosis and inflammation and has long been considered a potential therapeutic target in sepsis. Although thromboprophylaxis for venous thromboembolism with heparins is part of standard management for COVID-19, it also potentially attenuates organ dysfunction due to thrombotic sequela. In contrast, the effectiveness of anticoagulation with heparin, antithrombin, or thrombomodulin to reduce mortality has not conclusively been proven in sepsis. Nonetheless, thromboinflammation has also been reported as an important pathophysiologic mechanism in other critical illnesses, including heatstroke, trauma, and ischemia/reperfusion injury, and may provide a potential therapeutic target for future clinical studies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC; INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust (UCLH), Cardio-metabolic Programme-National Institute for Health and Care Research UCLH/UCL Biomedical Research Centres, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Borsi SH, Shoushtari MH, Raji H, Nezhad HH, Mal-Amir MD. The Efficacy of Daily Administration of Nebulized Heparin on the Prevention of Endotracheal Tube Blockage in Patients With Pneumonia. Cureus 2024; 16:e53244. [PMID: 38425613 PMCID: PMC10903965 DOI: 10.7759/cureus.53244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE Nosocomial infections pose a significant public health concern, impacting over 100 million people worldwide annually. Within this research, we investigated heparin nebulization through the endotracheal tube and its effect on preventing blockage due to clots and mucus plugs compared to normal saline. METHODS A double-blind clinical experiment was done on a cohort of 40 pneumonia patients who were intubated and hospitalized in the intensive care unit (ICU) at Imam Khomeini Hospital in Ahvaz, Iran. The individuals were randomly assigned to two groups of 20 patients using a random allocation technique. The initial cohort was administered 5000 IU of heparin diluted in 4 ccs of 0.9% normal saline every eight hours via a nebulizer through a tracheal tube. In contrast, the second cohort was given 5 ccs of normal saline as a nebulizer through a tracheal tube. The study compared the incidence of tracheal tube obstruction caused by mucus plug or clot, the occurrence of patient hypoxia resulting in emergency tracheal tube replacement, and the frequency of emergency tracheal tube suction due to partial obstruction caused by mucus plug in both the heparin and saline groups. RESULTS According to our data, the number of patients in the heparin group who could avoid the need for emergency tracheal tube replacement owing to blockage was more significant than in the ordinary saline group (P=0.013). Heparin was significantly correlated with the number of times emergency suction was required to remove a tracheal tube occlusion (P=0.01). Heparin had no significant effect on coagulation factors (international normalized ratio [INR], platelet [PLT], and partial thromboplastin time [PTT]), Acute Physiology and Chronic Health Evaluation (APACHE) score, pneumonia severity index (PSI), saturation of patients, or tracheal tube secretions. There was no statistically significant difference in total time spent in the intensive care unit (P=0.91). CONCLUSIONS Further studies are suggested to determine the effect of heparin nebulization on preventing endotracheal tube obstruction due to clots and mucus plugs in intubated ICU patients.
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Affiliation(s)
- Seyed Hamid Borsi
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Maryam Haddadzadeh Shoushtari
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Hanieh Raji
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Hooshmand Hosseini Nezhad
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Mehrdad Dargahi Mal-Amir
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
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Zhang Y, Li Q, Sun C, Gu Y, Qi Z, Li J. The effect of nebulized heparin on clinical outcomes in mechanically ventilated patients: a meta-analysis and review of the literature. J Int Med Res 2023; 51:3000605231201340. [PMID: 37815327 PMCID: PMC10566280 DOI: 10.1177/03000605231201340] [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: 03/07/2023] [Accepted: 08/29/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To determine the relationship between use of nebulized heparin and clinical outcomes in mechanically ventilated patients. METHODS The Medline, Embase, Web of Science, Cochrane Library, and PubMed databases were searched for relevant randomized controlled trials (RCTs), published between database inception and May 2022. Primary outcomes were intensive care unit (ICU) length of stay and in-hospital mortality; secondary outcomes included duration of mechanical ventilation, ventilator-free days (VFDs) in 28 days, and length of hospitalization. The study protocol was registered on PROSPERO (registration No: CRD42022345533). RESULTS A total of eight RCTs (651 patients) were included. Nebulized heparin was associated with reduced ICU length of stay (six studies; mean difference [MD] -1.10, 95% confidence interval [CI] -1.87, -0.33, I2 = 76%), reduced duration of mechanical ventilation (two studies; MD -2.63, 95% CI -3.68, -1.58, I2 = 92%) and increased VFDs in 28 days (two studies; MD 4.22, 95% CI 1.10, 7.35, I2 = 18%), without increased incidence of adverse events, such as bleeding; but was not associated with a reduction in length of hospitalization (three studies; MD -1.00, 95% CI -2.90, -0.90, I2 = 0%) or in-hospital mortality (five studies; odds ratio 1.10, 95% CI 0.69, 1.77, I2 = 0%). CONCLUSION Nebulized heparin reduces ICU length of stay and duration of mechanical ventilation in mechanically ventilated patients, but has no effect on length of hospitalization or mortality.
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Affiliation(s)
- Yi Zhang
- Department of Respiratory and Critical Care Medicine, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Qiankun Li
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Changan Sun
- Intensive Care Unit, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Yue Gu
- Department of Respiratory and Critical Care Medicine, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Zhijiang Qi
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China; National Centre for Respiratory Medicine, Beijing, China
| | - Jun Li
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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Shute JK. Heparin, Low Molecular Weight Heparin, and Non-Anticoagulant Derivatives for the Treatment of Inflammatory Lung Disease. Pharmaceuticals (Basel) 2023; 16:ph16040584. [PMID: 37111341 PMCID: PMC10141002 DOI: 10.3390/ph16040584] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Unfractionated heparin has multiple pharmacological activities beyond anticoagulation. These anti-inflammatory, anti-microbial, and mucoactive activities are shared in part by low molecular weight and non-anticoagulant heparin derivatives. Anti-inflammatory activities include inhibition of chemokine activity and cytokine synthesis, inhibitory effects on the mechanisms of adhesion and diapedesis involved in neutrophil recruitment, inhibition of heparanase activity, inhibition of the proteases of the coagulation and complement cascades, inhibition of neutrophil elastase activity, neutralisation of toxic basic histones, and inhibition of HMGB1 activity. This review considers the potential for heparin and its derivatives to treat inflammatory lung disease, including COVID-19, ALI, ARDS, cystic fibrosis, asthma, and COPD via the inhaled route.
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Affiliation(s)
- Janis Kay Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth PO1 2UP, UK
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Mohammadian Erdi A, Yousefian M, Isazadehfar K, Badamchi F. Evaluating the Efficacy of the National Early Warning Score in Predicting the Mortality of Stroke Patients Admitted to Intensive Care Units. Anesth Pain Med 2022; 12:e116358. [PMID: 35991775 PMCID: PMC9375957 DOI: 10.5812/aapm-116358] [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: 01/09/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background National Early Warning Score (NEWS) is a tool used to identify patients at risk. Scores are based on initial clinical observations, including heart rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, body temperature, and oxygen support. To date, few studies have been conducted on NEWS evaluation worldwide, and no study has been conducted in Iran. Objectives This study aims to evaluate the efficacy of the NEWS in predicting the mortality of stroke patients admitted to intensive care units (ICU). Methods The present cross-sectional study included 90 patients with a definitive diagnosis of cerebrovascular accident (CVA) based on symptoms and para-clinical evidence. At the beginning of admission to the ICU and up to first 24 hours of admission, all NEWS parameters were measured and evaluated. Results There was a significant relationship between systolic blood pressure, respiratory support, heart rate, and level of consciousness with patients’ discharge status. Also, there was no significant relationship between age, sex, respiratory rate, SPO2, and fever with discharge status. In addition, there was a significant relationship between clinical risk based on NEWS scoring system and patients’ status. Conclusions Our results showed a significant relationship between clinical risk based on NEWS scoring and patients’ discharge status so that there was a significant increase in mortality in patients with higher NEWS.
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Affiliation(s)
- Ali Mohammadian Erdi
- Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mahzad Yousefian
- Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
- Corresponding Author: Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran.
| | - Khatereh Isazadehfar
- Social Determinants of Health Research Center (SDH), Ardabil University of Medical Sciences, Ardabil, Iran
| | - Fatemeh Badamchi
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
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Mahmoodpoor A, Imani F, Soleimanpour H. COVID-19 Is Not Over and Needs Prediction Scores: An Endless Road! Anesth Pain Med 2021; 11:e121654. [PMID: 35291407 PMCID: PMC8909521 DOI: 10.5812/aapm.121654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ata Mahmoodpoor
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Soleimanpour
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
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