Disseminated intravascular coagulation: the application and utility of diagnostic tests

Sodium tanshinone IIA sulfonate improves inflammation, aortic endothelial cell apoptosis, disseminated intravascular coagulation and multiple organ damage in a rat heat stroke model

The aim of the present study was to investigate the effects of sodium tanshinone IIA sulfonate (STS) on inflammatory responses, aortic endothelial cell apoptosis, disseminated intravascular coagulation (DIC) and multiple organ damage in an animal model of classic heat stroke (CHS). The rats in the heat stroke (HS) and STS-treated heat stroke (STS-HS) groups were placed into a pre-warmed animal temperature controller (ATC) at 35°C. The moment at which the rectal temperature reached 43.5°C was considered as the time of onset of HS. In the HS groups, the rats were removed from the ATC and allowed to recover at 26°C for 0, 2, 6 or 12 h. In the STS-HS groups, the rats received femoral vein injections of 5–40 mg/kg STS immediately following the onset of HS and were subsequently placed at a temperature of 26°C to recover for 6 h. In the present study, the serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β and IL-6 were assessed using ELISA, and the numbers of apoptotic aortic endothelial cells were investigated using terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick-end labeling combined with immunofluorescence. In the HS groups, the serum levels of TNF-α, IL-1β and IL-6, as well as the numbers of apoptotic aortic endothelial cells were increased compared with the normothermic control group. Additionally, the plasma prothrombin time, activated partial thromboplastin time and D-dimer level were significantly increased in the HS group compared with the normothermic control group following recovery for 6 h. By contrast, the platelet count was decreased in the HS group compared with the normothermic control group. The serum levels of creatinine, blood urea nitrogen, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and lactate dehydrogenase were increased and histopathological damage to multiple organs was observed in the HS group following recovery for 6 h. In the STS-HS groups, cytokine levels and apoptotic aortic endothelial cell numbers were reduced compared with the HS group after 6 h recovery. STS (40 mg/kg) treatment additionally improved the serum levels of organ injury indicators and plasma indicators of coagulopathy, and prevented histopathological damage to multiple organs. These findings demonstrated that STS treatment may ameliorate multiple organ damage by attenuating inflammatory responses, aortic endothelial cell apoptosis and DIC in CHS. These results suggested that STS may hold potential as an alternative therapeutic strategy for the treatment of patients with HS.

The investigation and management of neonatal haemostasis and thrombosis

These guidelines address developmental aspects of neonatal haemostasis and thrombosis, the laboratory investigation of the neonate, and the diagnosis and clinical management of haemostatic and thrombotic conditions occurring in this period (defined as the first 4 weeks of life following birth). Relevant scientific papers were identified by a systematic literature review from Medline 1975-2000 using index terms which incorporated the various component subjects of these guidelines. Further publications were obtained from the references cited and from reviews known to the members of the working party and to the Haemostasis and Thrombosis Task Force. Evidence and graded recommendations presented in these guidelines are in accordance with the US Agency for Health Care Policy and Research, as described in the Appendix. It will be noted that there is a lack of a strong evidence base for many of the recommendations suggested, as the appropriate clinical and laboratory trials have not been and perhaps never will be undertaken in neonates. Most of the recommendations are therefore of Grade C evidence levels IV: higher levels are mentioned specifically throughout the document when relevant.

Fatal disseminated intravascular coagulation after autologous islet transplantation

Autologous islet transplantation after pancreatectomy has been used in the surgical management of patients with intractable pain secondary to chronic pancreatitis. Total or near total pancreatectomy invariably leads to exogenous insulin dependence in these patients unless they undergo islet transplantation. Transplantation of autologous islet cells harvested from the patient's pancreas into the liver through portal vein infusion has led to long-term euglycemia in 30% to 50% of patients. We report the development of disseminated intravascular coagulation and fatal hemorrhagic shock in a 36-year-old woman after total pancreatectomy and autologous islet transplantation through retrograde infusion into the splenic vein. We report the clinical and pathological findings and discuss the possible pathophysiological mechanisms involved in the development of disseminated intravascular coagulation after this procedure.

Transfusion therapy in emergency and critical care medicine

The administration of blood or its components can provide the life-saving element for a critically ill small animal patient. Shock from acute massive hemorrhage produces catastrophic cardiovascular changes requiring rapid, accurate resuscitation techniques for survival. Bleeding that occurs more slowly allows for the opportunity to discover and treat the inciting cause and to administer specific blood component.

Perioperative coagulopathy in patients undergoing primary cytoreduction

BACKGROUND

This study was performed to determine the frequency of a perioperative coagulopathy in patients undergoing primary cytoreduction for ovarian cancer or carcinoma of the peritoneum and to identify variables that might predict this phenomenon.

METHODS

A retrospective review of 90 patients undergoing primary cytoreduction for ovarian cancer or carcinoma of the peritoneum was performed at Cedars Sinai Medical Center. Univariate analysis was performed to test the relationship between 15 variables and coagulopathy status.

RESULTS

Six patients (6.7%) developed a perioperative coagulopathy that was unrelated to preoperative subcutaneous heparin or dilution. Coagulation disturbances developed intraoperatively before packed erythrocyte replacement equivalent to one blood volume. Four patients (4.4%) required a repeat laparotomy due to continued postoperative bleeding unresponsive to blood component replacement. Vascular pedicles were not the cause of bleeding in any patient. Univariate analysis demonstrated a significant association between perioperative coagulopathy and the following variables: ascites volume (P = 0.009), estimated blood loss (P = 0.002), preoperative serum albumin less than 3.5 g/dl (P < 0.0001), and metastasis greater than 10 cm (P = 0.033).

CONCLUSIONS

Patients undergoing primary cytoreduction who have ascites, preoperative serum albumin less than 3.5 g/dl, or metastases greater than 10 cm may be at increased risk for development of a perioperative coagulopathy.

Autologous bone marrow transplantation and factor XII, factor VII, and protein C deficiencies. Report of a new association and its possible relationship to endothelial cell injury

Four patients who underwent treatment with high-dose chemotherapy (HDC) and autologous bone marrow transplantation (ABMT) and in whom posttreatment deficiencies of Factor XII and protein C subsequently developed are reported. Factor VII or Factor X deficiencies also developed in several of these patients. Three of these patients experienced chemotherapy-related cardiac, hepatic, or pulmonary toxicity. It is believed by many that endothelial cell injury may be the underlying lesion responsible for these various organ system toxicities seen in the setting of ABMT, although direct evidence of this is lacking. It is proposed that the factor deficiencies described in this report may be an additional consequence of endothelial cell injury or dysfunction. These coagulation factor deficiencies may therefore serve as both a marker to follow these organ system toxicities with and as a useful tool to better study and understand the mechanisms underlying these events. Additionally, deficiencies of either Factor VII or Factor X developed in several patients that were of a sufficient magnitude such that factor replacement therapy would be indicated before any invasive procedures or in the event of significant hemorrhage.

Changes in blood coagulation parameters of red deer (Cervus elaphus) experimentally infected with malignant catarrhal fever

Changes in blood coagulation parameters were followed in four red deer (Cervus elaphus) experimentally infected with malignant catarrhal fever (MCF) of deer. Blood platelet counts, activated partial thromboplastin time (APTT), one-stage prothrombin time (OSPT), activated clotting time (ACT), plasma anti-thrombin III (ATIII) activity, fibrinogen degradation production (FDP) and fibrinogen levels were measured. Inoculated deer became pyrexic after 17 or 19 days. Thereafter they developed watery diarrhoea which rapidly became haemorrhagic. The course of the clinical disease ranged from four to six days before the animals were killed or died. All inoculated deer developed abnormalities in laboratory parameters of blood coagulation. These varied within and between animals, but the coagulation profiles of all four animals remained abnormal until death. Post-mortem findings included extensive systemic petechiation, severe haemorrhage in the alimentary canal and vasculitis with disseminated thrombosis. Abnormal coagulation parameters included extension of APTT and OSPT, increased FDP, decreased ATIII and platelet counts and increased fibrinogen levels. The increases in fibrinogen were compatible with the acute phase response. The other coagulation abnormalities and haemorrhage and thrombosis were indicative of disseminated intravascular coagulation (DIC) with consumption coagulopathy, ACT remained normal in all deer although final clot quality was considered poor.

Coagulation defects of aflatoxin intoxicated rabbits

Twelve New Zealand white rabbits were intoxicated with aflatoxin B1. Most rabbits developed a coagulation defect near the time of death. Immediately prior to death there were significant decreases in factors V, VII, and VIII coagulant activities and fibrinogen concentration without a change in plasma fibrin(ogen) degradation product concentration, platelet number, and detectable plasma fibrin monomers. Microscopic evidence of disseminated intravascular coagulation was present in one rabbit with marked, diffuse hepatic necrosis. Terminal serum albumin concentration was significantly correlated to plasma factors V and VII activities and fibrinogen concentration. The coagulation defect of aflatoxicosis is primarily due to diminished hepatic synthesis of coagulation factors except when hepatic necrosis is severe enough to initiate intravascular coagulation and consumption of coagulation factors.

Disseminated intravascular coagulation and purpura fulminans in a patient with Candida sepsis. Biopsy of purpura fulminans as an aid to diagnosis of systemic Candida infection

Disseminated intravascular coagulation and purpura fulminans developed in association with septicemia and meningitis due to Candida tropicalis in an 18-year-old female immunosuppressed renal allograft recipient. Although systemic Candida infection was initially suspected, blood cultures showed no growth of this organism until after its identification in the dermis of a skin biopsy specimen obtained from the site of purpura fulminans. This case illustrates the association between Candida sepsis and purpura fulminans, and demonstrates the usefulness of skin biopsy of purpura fulminans in the early diagnosis of Candida sepsis.