Hyper- and hypocoagulopathy in sepsis, the dos and don'ts - Nicole Juffermans - SSAI2017
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A talk by Nicole Juffermans at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Content delivered in collaboration between scanFOAM, SSAI & SFAI.
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Hyper- and hypocoagulopathy in sepsis, the dos and don'ts - Nicole Juffermans - SSAI2017
- 1. Coagulopathy in sepsis: the do’s and dont’s Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.) Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands Nicole Juffermans
- 2. I have no disclosures
- 4. TF VIIa Xa IIa prothrombin thrombin fibrinogen fibrin APC AT TFPI vWF Changes in sepsis fibrinolysis TF TF
- 5. Lab results in sepsis patients PT prolongend APTT prolonged platelets low D dimer high ++ AT low ++ PT N APTT N platelets low – N D dimer high AT low no DICDIC
- 6. TEG/ROTEM in sepsis patients Mixed results: normal, hyper- and hypo profiles Hypocoag dominates CT, R prolonged α angle decreased MCF, MA decreased Hypercoag dominates CT, R shortened α angle increased MCF, MA increased no DICDIC Muller, Crit Care 2014
- 7. Trombopenia is associated with mortality in ICU platelet count Claushuis, Blood 2016
- 8. Prolonged PT is associated with mortality in ICU Walsh, Crit Care Med 2010:38;1939
- 9. DIC is associated with mortality in ICU Angstwurm, Crit Care Med 2006;34:314
- 10. Thrombopenic sepsis is associated with increased cytokine production Claushuis, Blood 2016
- 11. Thrombocytopenic sepsis is associated with impaired host immune response Claushuis, Blood 2016
- 13. Risk of bleeding
- 14. Risk of bleeding in sepsis • Any bleeding 10-12 % • Major bleeding 2-5 % • Intracranial bleeding 0.5 % Prowess trial NEJM 2001, Kybersept trial JAMA 2001
- 15. Risk of bleeding in thrombocytopenic ICU patients HR (95% CI) 100-150 50-100 <50 Major bleed 2.0 (1.4-2.8) 3.5 (2.5-5.0) 3.5 (2.1-6.0) RBC transfusion 1.4 (1.3-1.6) 1.9 (1.6-2.2) 3.4 (2.5-4.6) ‘Safe’ threshold does not exist PROTECT study, Chest 2013
- 16. Risk of bleeding following procedures Risk < 1% regardless of platelet count or INR
- 17. Treatment to reduce bleeding risk
- 19. Platelet transfusion in patients with cerebral hemorrhage under antiplatelet therapy is associated with worse outcome death or dependent death or dependent PATCH trial, Lancet 2016
- 20. vWF Platelet transfusion: fuelling thrombi formation?
- 21. Platelets activate endothelial cells in vitro Urner, Plos One 2012
- 22. Platelet transfusion in trauma patients associated with decrease in platelet function J Surg Res 2017
- 23. Efficacy of platelet transfusion prior to invasive procedures Kor, Transfusion 2017
- 24. Kor, Transfusion 2017 No effect
- 25. Factors protecting against development of thrombocytopenia in the ICU PROTECT study, Chest 2013 HR (95% CI) 100-150 50-100 <50 Prophylactic LMWH 1.0 (0.8-1.3) 0.6 (0.5-0.8) 0.7 (0.5-1.0) Stress ulcer prophylaxis 0.9 (0.7-1.2) 0.8 (0.5-1.0) 1.1 (0.65-2.0)
- 26. Treatment to reduce bleeding risk
- 27. FFP increases factor levels in coagulopathic ICU patiens Muller, J Thromb Haem 2015
- 28. FFP also increases anticoagulant levels Muller, J Thromb Haem 2015
- 29. Net effect: thrombin generation is not altered by FFP Muller, J Thromb Haem 2015
- 30. • There is risk of bleeding, but major bleeds are rare • Risk-benefit of platelets when count is 10- 50: unknown • No rationale for FFP or antifibrinolytics Interim conclusions
- 32. Risk of thrombosis in sepsis Kaplan, Chest 2015
- 33. Treatment to reduce thrombosis risk
- 34. TF VIIa Xa IIa prothrombin thrombin fibrinogen fibrin APC AT TFPI vWF Changes in sepsis fibrinolysis TF TF
- 35. Antithrombin in sepsis with DIC • 30 RCTs, 4000 pats • RR for mortality 0.95 (0.88 – 1.03) • RR for bleeding 1.58 (1.35 – 1.84) • Low quality of trials Cochrane review 2016
- 36. TF VIIa Xa IIa prothrombin thrombin fibrinogen fibrin APC AT TFPI vWF Thrombomodulin in sepsis fibrinolysis TF TF aPC
- 37. rhTM reduces DIC in sepsis Hagiwara, BMJ open 2016
- 38. rhTM reduces DIC in sepsis TM placebo CCM 2013
- 39. • Treat underlying condition • Platelets when count < 10 x 109 /L; but sooner when risk of bleeding • Heparin prophylaxis recommended • Heparin treatment when there is thrombosis • AT/TM can be considered in DIC
- 40. Personal additions.. • Risk for major bleed in sepsis low • Risk-benefit of platelet transfusion when count is 10-50 is unclear • Prophylaxis prior to invasive procedures is probably not effective • Stress ulcer prophylaxis ?
- 41. Special issue on Transfusion in ICU just appeared sept 2017
Editor's Notes
- Factor 7a and TF complex result in activation of factor X and II which result in generation of thrombin
- Factor 7a and TF complex result in activation of factor X and II which result in generation of thrombin
- Factor 7a and TF complex result in activation of factor X and II which result in generation of thrombin
- Factor 7a and TF complex result in activation of factor X and II which result in generation of thrombin
- Factor 7a and TF complex result in activation of factor X and II which result in generation of thrombin