A Prospective Comparison of New Japanese Criteria for Disseminated Intravascular Coagulation : New Japanese Criteria Versus ISTH Criteria

In Japan, early diagnosis and early treatment of disseminated intravascular coagulation (DIC) based on the old Japanese criteria have greatly improved the outcomes of DIC patients with hematopoietic malignancy. However, the prognoses of critically ill patients with DIC have remained poor. To overcome this situation, new Japanese DIC criteria for critically ill patients were established in 2002. The new Japanese DIC criteria adopted a concept of coagulopathy associated with systemic inflammatory response syndrome. In the present study, we prospectively investigated the relationships between the new criteria and organ failure, prognosis, and other sets of DIC criteria. This study included 74 patients whose platelet counts were below 150 x 10^9/L. Daily DIC scores and sequential organ failure assessment scores were recorded from days 0 to 4 once the patient was included in the study. The new Japanese DIC criteria diagnosed DIC earlier than both the non-overt DIC and the old Japanese criteria did (p = 0.0005). The new Japanese criteria diagnosed more DIC patients prior to the establishment of multiple organ failure than the other sets (p = 0.023). The new Japanese criteria tended also to predict prognoses more efficiently than the other two sets. In conclusion, the diagnostic sensitivity of the new Japanese criteria was as high as that of the non-overt DIC criteria. Furthermore, the new Japanese criteria provided the earliest detection and most accurate outcome prediction of DIC among the DIC criteria sets

A Prospective Comparative Study of Three Sets of Criteria for Disseminated Intravascular Coagulation : ISTH Criteria vs Japanese Criteria

Clinical and laboratory criteria and a scoring system for disseminated intravascular coagulation (DIC) were recently published by the International Society on Thrombosis and Haemostasis (ISTH). In Japan, the DIC Diagnostic Standards published in 1988 have been widely used for more than 10 years. In a general intensive care unit, we prospectively compared the diagnostic properties of the overt DIC, non-overt DIC, and Japanese DIC criteria sets, and investigated the influences of each set on patient morbidity and mortality. Seventy-four patients with platelet counts below 150 x 10^9/L were included in this study. Blood samples were collected daily from day 0 to day 4 after inclusion in the study. The Japanese DIC included the overt DIC and both of these were included in the non-overt DIC. The Japanese DIC criteria diagnosed DIC earlier than the non-overt DIC criteria did (p = 0.020). The DIC patients diagnosed by the Japanese criteria and those diagnosed by the overt DIC criteria showed a higher incidence of multiple organ failure than those without DIC (p = 0.013 and p = 0.022, respectively). The Japanese and the non-overt DIC criteria tended to predict patient prognoses effectively. In conclusion, the Japanese and the non-overt DIC criteria are of value in predicting outcome. However, the non-overt DIC criteria take more time to diagnose DIC than the Japanese criteria do. A more precise clinical study is needed to determined appropriate specific criteria and cut-ff points in the non-overt DIC criteria set

The response of antithrombin III activity after supplementation decreases in proportion to the severity of sepsis and liver dysfunction

The decrease in the antithrombin III activity is thought to result from consumption by ongoing coagulation, degradation by neutrophil elastase, capillary leak syndrome, and impaired synthesis. A retrospective data analysis of patients with sepsis was conducted to investigate the response of antithrombin III activity after supplementation in patients with sepsis, and to determine what factors affect the response of antithrombin III activity. The study included 42 sepsis, 75 severe sepsis and 65 septic shock patients, who were administrated antithrombin III. Antithrombin III activity, platelet counts, coagulation and fibrinolytic markers were collected before administration and 24 hr after the supplementation. In the patients with septic shock, the response of antithrombin III activity after supplementation was 0.37 ± 1.21%/IU/kg body weight, which was significantly lower in comparison to those in the patients with sepsis (1.81 ± 1.75 ; P < 0.001) or severe sepsis (1.36 ± 1.65 ; P < 0.001). The patients with liver dysfunction had significantly lower response to antithrombin III activity than that of the patients without liver dysfunction (P < 0.0001). A stepwise multiple-linear regression analysis revealed that the severity of sepsis and liver function were independent predictors for the response to antithrombin III activity. These results suggest that the response to antithrombin III supplementation may be affected by both a systemic inflammation and impaired synthesis in patients with sepsis

重症骨盤骨折に対するダメージコントロールとしての腹腔内膀胱破裂の非手術的治療

There is a consensus that blunt traumatic intraperitoneal bladder rupture should undergo water-tight suturing and be decompressed by a transurethral catheter. This is the first report of the non-operative management of blunt traumatic intraperitoneal bladder rupture with a severe pelvic fracture. A 32-year-old male was run over by a power shovel, and brought to our emergency department. Upon arrival, he was in severe shock because of massive bleeding from a severe pelvic fracture. Transcatheter arterial embolization and an external fixation for the pelvic fracture was performed. Retrograde cystography showed an intraperitoneal bladder rupture. On the day of admission, the non-operative management of the intraperitoneal bladder rupture was performed to prevent additional bleeding. We could continue the conservative management on the day after admission because urine could be constantly drained. At one week after admission, the bladder rupture healed. The non-operative management for an intraperitoneal bladder rupture with a severe pelvic fracture is an important treatment modality in order to carry out damage control after a severe pelvic fracture. Such non-operative management can be continued when a celiotomy is not needed for other abdominal organ injuries, no intravesical bone spicule is detected, and urine can be constantly drained

Insufficient production of urinary trypsin inhibitor for elastase release promotes organ failure following cardiac arrest

To investigate the relationship between the inflammatory responses and post-resuscitation syndrome, we prospectively examined the serial changes of neutrophil elastase (NE), urinary trypsin inhibitor (UTI) and tumor necrosis factor-α (TNF-α) in successfully resuscitated patients following out-of-hospital cardiac arrest. This study included 36 patients with out-of-hospital cardiac arrests that wewere admitted to our intensive care unit after return of spontaneous circulation (ROSC). The twenty-two patients who died within 3 days after ROSC were defined as nonsurvivors. The fourteen patients who survived for more than 3 days after ROSC were defined as survivors. Eight healthy volunteers served as control group. Daily plasma levels of NE, UTI, and TNF-α were measured from days 1 to 5 after ROSC. Persistently high levels of TNF-α and NE were observed in both the survivors and nonsurvivors. In the two groups, the levels of UTI were significantly high and increased as time progressed. NE/UTI ratios were significantly higher in the nonsurvivors than in the survivors, especially on day 1. The nonsurvivors showed statistically higher scores according to the Sequential Organ Failure Assessment and they also had more organ failure than the survivors. In conclusion, an insufficient production of UTI for NE release and persistent high levels of TNF-α may contribute to the pathogenesis of post-resuscitation syndrome following out-of-hospital cardiac arrest

Sivelestat (Selective Neutrophil Elastase Inhibitor) Improves the Mortality Rate of Sepsis Associated With Both Acute Respiratory Distress Syndrome and Disseminated Intravascular Coagulation Patients

Introduction: Neutrophil elastase plays an important role in the development of acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) in sepsis. Sivelestat is a selective neutrophil elastase inhibitor. It is possible that sivelestat improves the outcome of septic patients associated with ARDS and DIC. Methods: A retrospective data analysis of septic patients associated with ARDS and DIC was conducted to investigate the effects of sivelestat. Observational period was 5days after admission to ICU. Results: The study included 167 septic patients associated with ARDS and DIC. Control group included 133 patients without sivelestat and sivelestat group included 34 patients started to de administered sivelestat on the admission to ICU. The lung injury scores and Pa_[O2]/Fi_[O2] ratio of the sivelestat group were significantly more severe than those of the control group from day 1 to day 4. On day 5, the lung injury score and Pa_[O2]/Fi_[O2] ratio of the sivelestat group improved to the same levels of those of the control group. The DIC score of sivelestat group improved on day 3 in comparison to day 1, those of control group remained unchanged until day 4. The length of ICU stay of the sivelestat group was significantly shorter than that of the control group. A stepwise multiple logistic-regression analysis showed the sivelestat administration to be an independent predictor of survival of the septic patients associated with both ARDS and DIC. Conclusions: The length of ICU stay of the sivelestat group was significantly shorter than that of the control group. In addition, sivelestat administration was found to be an independent predictor of survival of those patients

肝コンパートメント症候群を疑われ経動脈塞栓術にて治療した2症例

We herein present two cases suspected of having liver compartment syndrome that were successfully managed with transarterial embolization (TAE). The first patient was a 40-year-old female involved in a car accident. Contrast-enhanced computed tomography (CT) showed a large intraparenchymal hematoma and active hemorrhaging in the hematoma. Transarterial embolization was performed. A hepatofugal portal flow was only detected in the right lobe of the liver, and a normal antegrade flow was observed in the left lobe. The second patient was a 73-year-old man who had fallen down a flight of stairs. Contrast-enhanced CT showed a large intraparenchymal hematoma. On angiography, a small hemorrhage was observed and TAE was performed. A hepatofugal portal flow was detected in the right lobe of the liver. Liver compartment syndrome is defined as intraparenchymal hypertension induced by a large subcapsular hematoma in a patient with blunt hepatic injury. Liver compartment syndrome causes a disruption in the normal liver circulation and may result in either hepatic ischemia or Budd-Chiari syndrome. It is important to prevent an enlargement of the hematoma by applying TAE