Diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation
Diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation
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DOI：
10.1111/jth.14578
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发表时间：
2019-08-13
影响因子：
10.4
通讯作者：
Levi, Marcel
中科院分区：
文献类型：
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作者：
Iba, Toshiaki;Levy, Jerrold H.;Levi, Marcel
国际血栓与止血学会 (ISTH) 于 2001 年将弥散性血管内充血 (DIC) 定义为“一种获得性综合征，其特征是血管内凝血激活，并由于不同原因引起定位丧失，这些原因可能源自微脉管系统并导致微脉管系统损伤，如果足够严重，可能会导致器官功能障碍。” 1 目前的信息支持脓毒症中的 DIC 是一种由感染引起的凝血障碍的概念，但也代表一种导致内皮功能障碍的急性全身炎症反应。 2, 3 在脓毒症中，循环异常导致的内皮损伤和随后的组织损伤会导致多器官衰竭，随后的 DIC 是一种影响患者预后的血栓炎症反应。 4 尽管有多项随机对照试验 (RCT)，但抗凝治疗对脓毒症相关 DIC 的有效性仍存在争议；然而，这些研究是在脓毒症患者中进行的，但与并发 DIC 的情况不一致。最近的研究报告称，抗凝治疗可能会改善患有凝血障碍或 DIC 的脓毒症患者的预后，5, 6 以及大规模随机对照试验中抗凝治疗的类似亚组分析报告显示，仅在患有凝血障碍或 DIC 的亚组中，死亡率风险有更大降低的趋势。 7, 8 因此，我们认为识别患有凝血障碍的脓毒症患者对于靶向抗凝治疗至关重要。 9 然而，通过多次凝血试验对所有患者进行筛查的成本很高，因此，DIC 科学和标准化委员会 (SSC) 针对明显 DIC 的 ISTH 诊断标准提出了简单易用的诊断标准。 9 在入住重症监护病房 (ICU) 当天筛查明显的 DIC 与较低的死亡率相关，如果 2 天后重复筛查，这种相关性会变得更强，这表明 DIC 筛查本身可能会改善预后。 10 然而，患有晚期凝血病的患者，包括许多根据 ISTH 标准患有明显 DIC 的患者，可能会出现疾病进展，不再适合从抗凝治疗中获益。 11 因此，DIC SSC 提出了一个新的类别，用于识别 DIC 的早期阶段，称为“败血症诱发的凝血病”(SIC)。 12 SIC 诊断标准对于临床实践非常重要，有助于早期识别并为未来 DIC 研究的纳入标准提供指导。在本指导文件中，我们描述了公开 DIC 和 SIC 的不同特征，并概述了两步顺序
The International Society of Thrombosis and Haemostasis (ISTH) in 2001 defined disseminated intravascular congestion (DIC) as “an ac‐quired syndrome characterized by the intravascular activation of co‐agulation with loss of localization arising from different causes that can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction.” 1 Current in‐formation supports the concept that DIC in sepsis is a coagulation disorder induced by infection, but also represents an acute systemic inflammatory response that leads to endothelial dysfunction. 2, 3 In sepsis, endothelial injury and subsequent tissue injury due to circu‐latory abnormalities cause multi‐organ failure, and the ensuing DIC is a thromboinflammatory response that affects patient outcomes. 4 The effectiveness of anticoagulant therapy for sepsis‐associated DIC is controversial despite multiple randomized controlled trials (RCTs); however, these studies were performed in patients with sep‐sis but not consistently with concomitant DIC. Recent studies report that anticoagulant therapy may improve outcomes in septic patients with coagulopathy or DIC, 5, 6 and similarly subgroup analyses of an‐ticoagulant therapy in large‐scale RCTs reported trends toward a greater risk reduction in mortality only in the subgroup with coagu‐lopathy or DIC. 7, 8 As a result, we believe identifying septic patients with coagulopathy is pivotal for targeting anticoagulant therapy. 9 However, screening all patients with multiple coagulation tests is costly, and as a result, simple and easy‐to‐use diagnostic criteria have been proposed by the Scientific and Standardization Committee (SSC) on DIC of the ISTH diagnostic criteria for overt DIC. 9 Screening for overt DIC on the day of intensive care unit (ICU) admission was associated with lower mortality, and the association became stron‐ger if the screening was repeated 2 days later, suggesting that DIC screening by itself might lead to improved outcomes. 10 However, patients with advanced coagulopathy, including many with overt DIC based on ISTH criteria, may have illness progression that is no longer amenable to benefit from anticoagulant therapy. 11 Therefore, the DIC SSC proposed a new category identifying an earlier phase of DIC, called “sepsis‐induced coagulopathy”(SIC). 12 The SIC diag‐nostic criteria are important for clinical practice to facilitate early recognition and provide guidance for inclusion criteria for future DIC studies. In this guidance document, we describe the different char‐acteristics of overt DIC and SIC, and outline a two‐step sequential