Differential diagnoses for sepsis-induced disseminated intravascular coagulation: communication from the SSC of the ISTH

The pathophysiology, diagnosis, and management of sepsis-associated disseminated intravascular coagulation

BACKGROUND

The International Society on Thrombosis and Haemostasis (ISTH) released overt disseminated intravascular coagulation (DIC) diagnostic criteria in 2001. Since then, DIC has been understood as the end-stage consumptive coagulopathy and not the therapeutic target. However, DIC is not merely a decompensated coagulation disorder, but also includes early stages with systemic activation in coagulation. Thus, the ISTH has recently released sepsis-induced coagulopathy (SIC) criteria that can diagnose compensated-phase of coagulopathy with readily available biomarkers.

MAIN BODY

DIC is a laboratory-based diagnosis due to various critical conditions, although sepsis is the most common underlying disease. The pathophysiology of sepsis-associated DIC is multifactorial, and in addition to coagulation activation with suppressed fibrinolysis, multiple inflammatory responses are initiated by activated leukocytes, platelets, and vascular endothelial cells as part of thromboinflammation. Although overt DIC diagnostic criteria were established by ISTH to diagnose the advanced stage of DIC, additional criteria that can detect an earlier stage of DIC were needed for potential therapeutic considerations. Accordingly, the ISTH introduced SIC criteria in 2019 that are easy to use and require only platelet count, prothrombin time-international normalized ratio, and Sequential Organ Failure Assessment Score. SIC score can be used to evaluate disease severity and determine the timing of potential therapeutic interventions. One of the major disadvantages in treating sepsis-associated DIC is the lack of availability of specific therapeutic approaches beyond treating the underlying infection. Clinical trials to date have failed because included patients who were not coagulopathic. Nevertheless, in addition to infection control, anticoagulant therapy will be the choice for sepsis-associated DIC. Therefore, the efficacy of heparin, antithrombin, and recombinant thrombomodulin has to be proven in future clinical studies.

CONCLUSION

It is necessary to develop a novel therapeutic strategy against sepsis-associated DIC and improve the outcomes. Consequently, we recommend screening and monitoring DIC using SIC scoring system.

Diabetes as one of the long-term COVID-19 complications: from the potential reason of more diabetic patients' susceptibility to COVID-19 to the possible caution of future global diabetes tsunami

According to recent researches, people with diabetes mellitus (type 1 and 2) have a higher incidence of coronavirus disease 2019 (COVID-19), which is caused by a SARS-CoV-2 infection. In this regard, COVID-19 may make diabetic patients more sensitive to hyperglycemia by modifying the immunological and inflammatory responses and increasing reactive oxygen species (ROS) predisposing the patients to severe COVID-19 and potentially lethal results. Actually, in addition to COVID-19, diabetic patients have been demonstrated to have abnormally high levels of inflammatory cytokines, increased virus entrance, and decreased immune response. On the other hand, during the severe stage of COVID-19, the SARS-CoV-2-infected patients have lymphopenia and inflammatory cytokine storms that cause damage to several body organs such as β cells of the pancreas which may make them as future diabetic candidates. In this line, the nuclear factor kappa B (NF-κB) pathway, which is activated by a number of mediators, plays a substantial part in cytokine storms through various pathways. In this pathway, some polymorphisms also make the individuals more competent to diabetes via infection with SARS-CoV-2. On the other hand, during hospitalization of SARS-CoV-2-infected patients, the use of some drugs may unintentionally lead to diabetes in the future via increasing inflammation and stress oxidative. Thus, in this review, we will first explain why diabetic patients are more susceptible to COVID-19. Second, we will warn about a future global diabetes tsunami via the SARS-CoV-2 as one of its long-term complications.

Intracellular communication and immunothrombosis in sepsis

Inflammation and coagulation are the critical responses to infection that include leukocytes, platelets, and vascular endothelial cells responding in concert to eradicate the invading pathogen. In sepsis, a variety of cell surface receptors, including toll-like receptors, Fcγ-receptors, G-protein-coupled receptors, and adhesion receptors, detect the pathogens and elicit thromboinflammatory responses. Concurrently, the molecular patterns released from host damaged cells accelerate the immune responses through binding to the same pattern recognition receptors. Cytokines, chemokines, and extracellular vesicles are important mediators for amplifying the responses to distant cells as part of the systemic response to infections. At the same time, cells communicate with each other via direct contact, adhesion molecules, paracrine mediators, and tunneling nanotubes, which are important for regulating inflammation and thrombus formation. Despite increasing attention to immunothrombosis in sepsis, these close communication systems are less understood but play a critical role in host defense mechanisms. In this review, cellular activation and direct intercellular communication systems in sepsis with a focus on the coagulation response will be considered.

Increased respiratory dead space could associate with coagulation activation and poor outcomes in COVID-19 ARDS

PURPOSE

To determine whether VDPhys/VT is associated with coagulation activation and outcomes.

MATERIALS AND METHODS

We enrolled patients with COVID-19 pneumonia who were supported by invasive mechanical ventilation and were monitored using volumetric capnography. Measurements were performed during the first 24 h of mechanical ventilation. The primary endpoint was the likelihood of being discharge alive on day 28.

RESULTS

Sixty patients were enrolled, of which 25 (42%) had high VDPhys/VT (>57%). Patients with high vs. low VDPhys/VT had higher APACHE II (10[8-13] vs. 8[6-9] points, p = 0.002), lower static compliance of the respiratory system (35[24-46] mL/cmH₂O vs. 42[37-45] mL/cmH₂O, p = 0.005), and higher D-dimer levels (1246[1050-1594] ng FEU/mL vs. 792[538-1159] ng FEU/mL, p = 0.001), without differences in P/F ratio (157[112-226] vs. 168[136-226], p = 0.719). Additionally, D-dimer levels correlated with VDPhys/VT (r = 0.530, p < 0.001), but not with the P/F ratio (r = -0.103, p = 0.433). Patients with high VDPhys/VT were less likely to be discharged alive on day 28 (32% vs. 71%, aHR = 3.393[1.161-9.915], p = 0.026).

CONCLUSIONS

In critically ill COVID-19 patients, increased VDPhys/VT was associated with high D-dimer levels and a lower likelihood of being discharged alive. Dichotomic VDPhys/VT could help identify a high-risk subgroup of patients neglected by the P/F ratio.

Hemostatic system and COVID-19 crosstalk: A review of the available evidence

Since the discovery of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its resultant coronavirus disease 2019 (COVID-19) pandemic, respiratory manifestations have been the mainstay of clinical diagnosis, laboratory evaluations, and radiological investigations. As time passed, other pathological aspects of SARS-CoV-2 have been revealed. Various hemostatic abnormalities have been reported since the rise of the pandemic, which was sometimes superficial, transient, or fatal. Mild thrombocytopenia, thrombocytosis, venous, arterial thromboembolism, and disseminated intravascular coagulation are among the many hemostatic events associated with COVID-19. Venous thromboembolism necessitating therapeutic doses of anticoagulants is more frequently seen in severe cases of COVID-19, especially in patients admitted to intensive care units. Hemorrhagic complications rarely arise in COVID-19 patients either due to a hemostatic imbalance resulting from severe disease or as a complication of over anticoagulation. Although the pathogenesis of coagulation disturbance in SARS-CoV-2 infection is not yet understood, professional societies recommend prophylactic antithrombotic therapy in severe cases, especially in the presence of abnormal coagulation indices. The review article discusses the various available evidence on coagulation disorders, management strategies, outcomes, and prognosis associated with COVID-19 coagulopathy, which raises awareness about the importance of anticoagulation therapy for COVID-19 patients to guard against possible thromboembolic events.

COVID-19 and Thrombosis Complication in Children

Since it was discovered in Wuhan in December 2019, most studies on COVID-19 have been centered on symptomatic adults. An expanded pro-inflammatory cytokine reaction, abnormal clot formation, overactive platelets, and hypercoagulable state are among the well-known clinical characteristics of endothelial dysfunction that may arise in patients with COVID-19. These conditions can lead to venous thromboembolism, arterial thrombosis, and pulmonary embolism. To date, the predominance of thromboembolic complications in children infected with severe acute respiratory syndrome coronavirus 2 has not been fully documented, and there is no explicit recommendation for the prevention of thrombosis in children.

Phenotype-oriented anticoagulant therapy for sepsis: still a work in progress

Coagulation disorders ranging from subtle changes in coagulation parameters to fatal disseminated intravascular coagulation (DIC) are common in septic patients. Coagulation activation is considered to be one of the most important factors contributing to multiple organ dysfunction syndrome (MODS) in sepsis. Anticoagulant therapy is, therefore, necessary to prevent MODS, but eligibility criteria remain controversial. Sepsis is a highly heterogeneous syndrome, which could explain the negative results of clinical studies on the treatment of sepsis. Recently, sepsis has been subdivided into several phenotypes with different therapeutic outcomes. At present, septic patients with dysfunctional coagulation expressed as increased D-dimer and fibrin/fibrinogen degradation products (FDPs) are considered to be candidates for anticoagulant therapy. In this review, we aimed to describe the features of different septic phenotypes. We also discuss factors that contribute to controversies in this area, and challenges in defining which septic phenotypes are good candidates for anticoagulant therapy.

Retinal findings of COVID-19 patients using Ocular coherence tomography angiography two to three months after infection: Ocular appearance recovered COVID-19 patient

Purpose

The aim of this study was to evaluate the ocular disorders in COVID-19 patients, two to three months after infection.

Methods

In this cross-sectional, historically controlled study, fifty-one COVID-19 patients were compared with thirty-seven age, and gender-matched healthy individuals. After complete ophthalmological examination, all participants underwent peripapillary and macular optical coherence tomography, and optical coherence tomography angiography (OCTA) measurements (OptoVue Inc, Freemont, CA, USA).

Results

The time between the initial onset of symptoms, and ophthalmologic examination was 63.31±15.21 (40–95 days). Ophthalmic examination of all the recovered COVID-19 patients was within normal range. None of the peripapillary and macular OCTA parameters were significantly different between the two groups with pairwise comparisons, but after adjusting for age, gender, axial length, and signal strength index (SSI), recovered COVID-19 eyes showed a significant increase in peripapillary retinal nerve fiber (RNFL) thickness, superficial, and deep macular vessel densities in parafoveal and perifoveal regions compared with healthy control eyes (p<= 0.05). Inner retinal thickness overall is higher in recovered COVID-19 eyes compared to healthy eyes after adjustment.

Conclusion

Patients with moderate-intensity SARS-CoV-2 pneumonia had altered peripapillary and macular vessel density compared to healthy subjects. Further investigation is warranted to analyze the correlation of these changes with disease severity as well as evolution of these changes over time.

Cellular and molecular mechanisms in COVID-19 coagulopathy: role of inflammation and endotheliopathy

INTRODUCTION

Coronavirus 2 (CoV-2) infection or coronavirus disease 2019 (COVID-19) is frequently associated with microvascular thrombosis.The microthrombosis in COVID-19 is the result of the interplay between inflammation and endotheliopathy. Elevated interleukin-6 (IL-6) characterizes COVID-19 inflammation resulting in endotheliopathy and coagulopathy marked by elevated D-dimer (DD). Aim of this study is to identify and to describe the coagulation changes in 100 moderate COVID-19 patients having lung involvement and to determine the association of coagulopathy with the severity and prognosis.

METHODS

Inflammation, endothelial and coagulation molecules were measured in moderate and mild disease.

RESULTS

IL-6 and tumor necrosis factor-α (TNF-α) and tissue factor (TF), von Willebrand factor (VWF), and tissue factor pathway inhibitor (TFPI) significantly increased in moderate disease as well as D-dimer, thrombin antithrombin complex (TAT), Fibrinogen (Fib), platelet factor-4 (PF4), β-thromboglobulin (β-TG), P-selectin, and platelet adhesion. Shortened clotting time (CT) and clot formation time (CFT), high maximum clot firmness (MCF) and low LY at 30 min were present in 100% of moderate COVID-19 patients compared with mild COVID-19 patients.

CONCLUSIONS

These findings demonstrate that moderate COVID-19 has a profound inflammation associated with severee ndotheliopathy and intense coagulation activation uncontrolled by TFPI. Attention should be paid to coagulopathy in COVID-19. Closely monitoring of coagulation and application of appropriate anticoagulation may improve the prognosis of moderate COVID-19 and to prevent the progression to severe COVID-19 disease.

COVID-19-associated Coagulopathy and Thromboembolism: Determination of their Patterns and Risk Factors as Predictors of Mortality Among Severe COVID-19 Patients

BACKGROUND

Corona virus disease 2019 (COVID-19) is associated with coagulopathy (CAC) and venous thromboembolism (VTE). These are well-reported complications of COVID-19 infection. Earlier publications have shown that CAC and thromboembolism are predictors of mortality among COVID-19 patients with severe disease.

MATERIAL AND METHODS

A prospective study was conducted in the Intensive Care Unit (ICU) where all confirmed COVID-19 patients were enrolled and followed until death or ICU discharge. CAC, VTE, along with all comorbidities were recorded. Predictors of mortality were determined by univariate and multivariate regression.

RESULTS

Among 261 patients with COVID-19, 48.3% survived and 51.7% died. CAC was present in 53.2% and 76.3% of the survivors and non-survivors, respectively (p<0.001); 89 patients (31.4%) had VTE (p=0.36) and 11 patients (4.2%) had arterial thrombosis (p=0.76) among survivors and non-survivors. Age between 71-80 years (p=0.009), male gender (p=0.045), CAC (p<0.001), comorbidities like chronic kidney disease (CKD, p=0.013), chronic obstructive pulmonary disease (COPD, p=0.001) and asthma (p=0.046), were significant predictors of mortality.

CONCLUSION

A severe complication of COVID-19 is CAC, such as sepsis-induced coagulopathy, overt disseminated-coagulopathy and VTE. Old age, various comorbidities (e.g. COPD, CKD or asthma), CAC, VTE (pulmonary embolism) and coagulation parameters with critical severity score (D-dimers, platelets, prothrombin time) and the SOFA (Sequential Organ Failure Assessment) score were significant predictors of mortality among COVID-19 patients.

Adverse Outcome in Non-Severe COVID-19: Potential Diagnostic Coagulation Tests

COVID-19-associated coagulopathy (CAC) identifies the coagulation changes in coronavirus disease 2019 (COVID-19) and is responsible for thrombosis. CAC has been studied in critical and severe stage COVID-19 disease through tests including the D-Dimer (DD), prothrombin time (PT), thromboplastin partial time (PTT), platelet count, fibrinogen (Fib), and platelet factor 4 (PF4) tests. However, these tests have some limitations. The aim of this study was to identify more accurate warning tests for early recognition of CAC and to prevent its deterioration to disseminated intravascular coagulation (DIC). First, we measured Interleukin-1α (IL-1α) and IL-8, and tissue factor pathway inhibitor (TFPI) as inflammation and endothelial damage markers, respectively. Second, we measured thrombin antithrombin complex (TAT), β-Thromboglobulin (β-TG), and thromboelastometric parameters including clotting time (CT), clot formation time (CFT), clot firmness (MCF), and clot lysis at 30 min (LY-30), as markers of coagulation and platelet activation. This study included 100 non-severe patients with COVID-19 that developed pulmonary embolism (PE) compared to 80 healthy patients. IL-1α and IL-8, and TFPI were higher as well as TAT and β-TG and thromboelastometric parameters, indicating hypercoagulability. If confirmed in other studies, these results could help in predicting the deterioration of non-severe COVID-19 disease, thereby reducing hospitalizations and health costs.

Prognostic nutritional index as indicator of immune nutritional status of patients with COVID-19

Purpose: This study aimed to investigate the effect of the nutritional status, as assessed by the prognostic nutritional index (PNI) on the disease prognosis of patients with COVID-19. Methods: This retrospective study included 282 patients with COVID-19. The PNI score of all patients, 147 of whom were male, with a mean age of 56.4±15.3 years, was calculated. According to the PNI score, the patients with normal and mild malnutrition constituted group-1 (n=159) and the patients with moderate-to-severe and serious malnutrition constituted group-2 (n=123). Results: The PNI score was correlated with age (r=-0.146, p=0.014); oxygen saturation (r=0.190, p=0.001); heart rate (r=-0.117, p=0.05); hospitalization duration (r=-0.266, p<0.001); white blood cells (r=0.156, p=0.009); hemoglobin (r=0.307, p<0.001); C-reactive protein (CRP) (r=-0.346, p<0.001); creatinine (r=-0.184, p=0.002); D-dimer (r=-0.304, p<0.001); ferritin (r=-0.283, p<0.001); procalcitonin (r=-0.287, p<0.001); the confusion, urea, respiratory rate, blood pressure, and age ≥65 years score (r=-0.217, p<0.001); and the quick sequential organ failure assessment score (r=-0.261, p<0.001) in patients with COVID-19. Mortality was significantly higher in Group 2 (p<0.001). Survival was significantly higher if PNI score was >41.2 (p<0.001, sensitivity: 78.7% and specificity: 84.2%). In multivariate regression analysis, among various other parameters, only PNI score and oxygen saturation had a significant effect on the disease course (p=0.02 and p=0.045, respectively). Conclusion: PNI, calculated from the serum albumin concentration and total lymphocyte count, is a simple and objective indicator that assesses the immune nutritional status of patients with COVID-19. The presence of malnutrition has a high predictive value in predicting the severity of COVID-19. Our data suggest that the PNI might be useful for risk stratification of patients with COVID-19 in clinical practice.

The diagnostic value of neutrophil to lymphocyte ratio in determining the severity of COVID-19

Background: Changes in hematological parameters play a role in the pathogenesis of coronavirus disease 2019 (COVID-19). We aimed to investigate the significance of neutrophil-lymphocyte ratio (NLR) and hematologic parameters in determining the severity of COVID-19. Methods: This retrospective cross-sectional study was conducted on adult patients diagnosed with COVID-19 in two pandemic hospitals between 01, April, and 01, July 2020. Using the COVID-19 diagnostic criteria of the world health organization (WHO), the patients were divided into two groups as severe and non-severe. Demographic and clinical characteristics, white blood cell (WBC), neutrophil, lymphocyte and platelet counts, and NLR of all patients were examined at the first admission. Multivariate analyzes were performed to determine the independent predictive data and ROC analysis to test the diagnostic accuracy of the hematological parameters. Results: Of the 381 patients included in the study, 42 (11%) had severe COVID-19 infection. While the mean NLR was 7.61±7.48 in patients with severe COVID-19, the mean NLR of non-severe patients was 2.97±2.37 (95% CI: 2.294 to 6.984, p<0.001). Long duration of hospital stay, elevated NLR ratio, female gender were predictive variables of severe COVID-19 cases (OR =0.833, 95% CI: 0.744 to 0.934, p=0.002; OR=0.195, 95% CI: 0.057 to 0.6731, p=0.010; OR=0.664, 95% CI: 0.501 to 0.881, p=0.005, respectively). In ROC analysis, NLR ratio had 2.625 optimum cut-off value, 60% specificity (95% CI: 54.7 to 65.4), 86% sensitivity (95% CI: 71.5 to 94.6), positive likelihood ratio (PLR) of 4.2 (95% CI: 2.0 to 8.9) and negative likelihood ratio (NLR) of 0.46 (95% CI: 0.4 to 0.6) for severe COVID-19 cases. Conclusion: The results of this study revealed that there might be a relationship between elevated NLR and severity in COVID-19 cases. IMC J Med Sci 2022; 16(1): 001 *Correspondence: Dr. Umut Gulacti, Adiyaman University Training and Research Hospital, Emergency Medicine, Adiyaman, Turkey. E-mail: umutgulacti@gmail.com

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

The Roles of Coagulation Disorder and Microthrombosis in Sepsis: Pathophysiology, Diagnosis, and Treatment

The diagnostic criteria of overt disseminated intravascular coagulation (DIC) were established by the International Society on Thrombosis and Haemostasis (ISTH) in 2001. Since then, DIC has long been associated with adverse outcomes. However, recent advances in sepsis shed light on the role of coagulation disorders in the progression of sepsis. Currently, inflammation and coagulation are recognized as the two drivers that promote organ dysfunction in sepsis and septic shock. The ISTH has published new diagnostic criteria for improved management, namely sepsis-induced coagulopathy (SIC), in 2017. SIC is a pragmatic scoring system composed of platelet count, prothrombin time, and organ dysfunction score to detect the early-stage of sepsis-associated DIC. Since overt DIC represents an uncompensated coagulation disorder, a two-step approach using SIC and overt DIC criteria is a novel strategy to evaluate the severity and manage this challenging complication. Although there is no globally agreed on anticoagulant therapy for DIC, the Japanese Surviving Sepsis Campaign Guidelines 2020 recommend using antithrombin and recombinant thrombomodulin for sepsis associated DIC. Since research in this area has been previously reported, an international collaborative study is necessary to develop future diagnostic tools and treatment strategies.

COVID-19: Thrombosis, thromboinflammation, and anticoagulation considerations

Vascular endothelial injury is a hallmark of acute infection at both the microvascular and macrovascular levels. The hallmark of SARS‐CoV‐2 infection is the current COVID‐19 clinical sequelae of the pathophysiologic responses of hypercoagulability and thromboinflammation associated with acute infection. The acute lung injury that initially occurs in COVID‐19 results from vascular and endothelial damage from viral injury and pathophysiologic responses that produce the COVID‐19–associated coagulopathy. Clinicians should continue to focus on the vascular endothelial injury that occurs and evaluate potential therapeutic interventions that may benefit those with new infections during the current pandemic as they may also be of benefit for future pathogens that generate similar thromboinflammatory responses. The current Accelerating COVID‐19 Therapeutic Interventions and Vaccines (ACTIV) studies are important projects that will further define our management strategies. At the time of writing this report, two mRNA vaccines are now being distributed and will hopefully have a major impact on slowing the global spread and subsequent thromboinflammatory injury we see clinically in critically ill patients.

Limb ischemia in patients with COVID-19

This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19’s relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.

Consumptive coagulopathy is associated with a disturbed host response in patients with sepsis

BACKGROUND

A prolonged prothrombin time (PT) is a common feature in sepsis indicating consumptive coagulopathy.

OBJECTIVES

To determine the association between a prolonged PT and aberrations in other host response mechanisms in sepsis.

METHODS

Patients admitted to the intensive care unit with sepsis were divided in quartiles according to the highest PT value measured within 24 h after admission. The host response was evaluated by measuring 19 plasma biomarkers reflecting pathways implicated in sepsis pathogenesis and by blood leukocyte gene expression profiling.

MEASUREMENTS AND MAIN RESULTS

Of 1524 admissions for sepsis, 386 (25.3%) involved patients with a normal PT (≤12.7 s); the remaining quartiles entailed 379 (24.9%) patients with a slightly prolonged PT (12.8 ≤ PT ≤ 15.0 s), 383 (25.1%) with an intermediately prolonged PT (15.1 ≤ PT ≤ 17.2 s), and 376 (24.7%) with an extremely prolonged PT (≥17.3 s). While patients with an extremely prolonged PT showed an increased crude mortality up to 1 year after admission, none of the prolonged PT groups was independently associated with 30-day adjusted mortality. Comparison of the host response between patients with a normal PT or an extremely prolonged PT matched for baseline characteristics including severity of disease showed that an extremely prolonged PT was associated with impaired anticoagulant mechanisms, a more disturbed endothelial barrier integrity and increased systemic inflammation, and blood leukocyte transcriptomes indicating more prominent metabolic reprogramming and protein catabolism.

CONCLUSION

A prolonged PT is associated with stronger anomalies in pathways implicated in the pathogenesis of sepsis, suggesting that activation of coagulation impacts other host response mechanisms.

Severe acute respiratory syndrome coronavirus 2 for physicians: Molecular characteristics and host immunity (Review)

Recently, severe acute respiratory syndrome (SARS) coronavirus (CoV) 2 (SARS‑CoV‑2)‑causing CoV disease 2019 (COVID‑19) emerged in China and has become a global pandemic. SARS‑CoV‑2 is a novel CoV originating from β‑CoVs. Major distinctions in the gene sequences between SARS‑CoV and SARS‑CoV‑2 include the spike gene, open reading frame (ORF) 3b and ORF 8. SARS‑CoV‑2 infection is initiated when the virus interacts with angiotensin‑converting enzyme 2 (ACE2) receptors on host cells. Through this mechanism, the virus infects the alveolar, esophageal epithelial, ileum, colon and other cells on which ACE2 is highly expressed, causing damage to target organs. To date, host innate immunity may be the only identified direct factor associated with viral replication. However, increased ACE2 expression may upregulate the viral load indirectly by increasing the baseline level of infectious virus particles. The peak viral load of SARS‑CoV‑2 is estimated to occur ~10 days following fever onset, causing patients in the acute stage to be the primary infection source. However, patients in the recovery stage or with occult infections can also be contagious. The host immune response in patients with COVID‑19 remains to be elucidated. By studying other SARS and Middle East respiratory syndrome coronaviruses, it is hypothesized that patients with COVID‑19 may lack sufficient antiviral T‑cell responses, which consequently present with innate immune response disorders. This may to a certain degree explain why this type of CoV triggers severe inflammatory responses and immune damage and its associated complications.

No Evidence for Classic Thrombotic Microangiopathy in COVID-19

Background: Coronavirus disease-2019 (COVID-19) triggers systemic infection with involvement of the respiratory tract. There are some patients developing haemostatic abnormalities during their infection with a considerably increased risk of death. Materials and Methods: Patients (n = 85) with SARS-CoV-2 infection attending the University Medical Center, Mainz, from 3 March to 15 May 2020 were retrospectively included in this study. Data regarding demography, clinical features, treatment and laboratory parameters were analyzed. Twenty patients were excluded for assessment of disseminated intravascular coagulation (DIC) and thrombotic microangiopathy (TMA) due to lack of laboratory data. Results: COVID-19 patients (n = 65) were investigated, 19 with uncomplicated, 29 with complicated, and 17 with critical course; nine (13.8%) died. Seven patients showed overt DIC according to the ISTH criteria. The fibrinogen levels dropped significantly in these patients, although not below 100 mg/dl. Hallmarks of TMA, such as thrombocytopenia and microangiopathic haemolytic anaemia, were not detected in any of our COVID-19 patients. ADAMTS13 activity was mildly to moderately reduced in 4/22 patients, all having strongly elevated procalcitonin levels. Conclusion: DIC occurred in 7/65 COVID-19 patients but fibrinogen and platelet consumption were compensated in almost all. ADAMTS13 assays excluded TTP and hallmarks of classic TMA were absent in all investigated patients. We hypothesize that the lacking erythrocyte fragmentation and only mild platelet consumption in severe COVID-19 are due to a microangiopathy predominantly localized to the alveolar microcirculation with a low blood pressure gradient.

Arterial Thrombotic Events in Adult Inpatients With COVID-19

OBJECTIVE

To evaluate the clinical course of and risk factors for arterial thrombotic events in adult inpatients with coronavirus disease 2019 (COVID-19).

METHODS

All consecutive adult patients admitted for COVID-19 infection in a referral center in France and discharged from the hospital between April 1 and April 30, 2020, were included. All arterial thrombotic events that occurred through discharge were considered for analysis. Epidemiologic, demographic, clinical, laboratory, treatment, and outcome data were extracted from electronic medical records with use of a standardized data collection form.

RESULTS

Overall, 531 COVID-19+ patients were analyzed. Among them, 30 (5.6%) experienced arterial thrombotic events. Arterial thrombotic events in the setting of COVID-19 infection happened at a median of 11 (5-20) days after the first symptoms of infection; occurred in high-risk patients according to traditional cardiovascular risk factors; had an atypical pattern, such as thrombosis of the aorta, upper limb, or renal arteries or cerebral microvasculopathy in 7 (23.3%) cases; and were associated with an in-hospital mortality rate of 40%. Arterial thrombotic events increased the risk of death by 3-fold in COVID-19+ patients (hazard ratio, 2.96; 95% CI, 1.4 to 4.7; P=.002). A subdistribution survival hazard model showed that a concentration of D-dimer above 1250 ng/mL increased the risk of arterial thrombotic events in COVID-19+ patients by more than 7 (subdistribution hazard ratio, 7.68; 95% CI, 2.9 to 20.6; P<.001).

CONCLUSION

A dramatically high rate of in-hospital death was observed in patients who suffered arterial thrombotic events in the setting of COVID-19 infection. A D-dimer level above 1250 ng/mL at entry may identify COVID-19+ patients at risk for arterial thrombotic events.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

The dynamic association between COVID-19 and chronic disorders: An updated insight into prevalence, mechanisms and therapeutic modalities

The devastating pandemic of coronavirus disease 2019 (COVID-19) has caused thousands of deaths and left millions of restless patients suffering from its complications. Increasing data indicate that the disease presents in a severe form in patients with pre-existing chronic conditions like cardiovascular diseases, diabetes, respiratory system diseases, and renal diseases. This denotes that these patients are more susceptible to COVID-19 and have higher mortality rates compared to patients with no comorbid conditions. Several factors can explain the heightened susceptibility and fatal presentation of COVID-19 in these patients, for example, the enhanced expression of the angiotensin-converting enzyme-2 (ACE2) in specific organs, cytokine storm, and drug interactions contribute to the increased morbidity and mortality. Adding to the findings that individuals with pre-existing conditions may be more susceptible to COVID-19, it has also been shown that COVID-19 can induce chronic diseases in previously healthy patients. Therefore, understanding the interlinked relationship between COVID-19 and chronic diseases helps in optimizing the management of susceptible patients. This review comprehensively described the molecular mechanisms that contribute to worse COVID-19 prognosis in patients with pre-existing comorbidities such as diabetes, cardiovascular diseases, respiratory diseases, gastrointestinal and renal diseases, blood disorders, autoimmune diseases, and finally, obesity. It also focused on how COVID-19 could, in some cases, lead to chronic conditions as a result of long-term multi-organ damage. Lastly, this work carefully discussed the tailored management plans for each specific patient population, aiming to achieve the best therapeutic outcome with minimum complications.

COVID-19 and diabetes mellitus: from pathophysiology to clinical management

Initial studies found increased severity of coronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in patients with diabetes mellitus. Furthermore, COVID-19 might also predispose infected individuals to hyperglycaemia. Interacting with other risk factors, hyperglycaemia might modulate immune and inflammatory responses, thus predisposing patients to severe COVID-19 and possible lethal outcomes. Angiotensin-converting enzyme 2 (ACE2), which is part of the renin-angiotensin-aldosterone system (RAAS), is the main entry receptor for SARS-CoV-2; although dipeptidyl peptidase 4 (DPP4) might also act as a binding target. Preliminary data, however, do not suggest a notable effect of glucose-lowering DPP4 inhibitors on SARS-CoV-2 susceptibility. Owing to their pharmacological characteristics, sodium-glucose cotransporter 2 (SGLT2) inhibitors might cause adverse effects in patients with COVID-19 and so cannot be recommended. Currently, insulin should be the main approach to the control of acute glycaemia. Most available evidence does not distinguish between the major types of diabetes mellitus and is related to type 2 diabetes mellitus owing to its high prevalence. However, some limited evidence is now available on type 1 diabetes mellitus and COVID-19. Most of these conclusions are preliminary, and further investigation of the optimal management in patients with diabetes mellitus is warranted.

Evaluation of Sepsis-Induced Coagulopathy in Critically Ill Pediatric Patients with Septic Shock

BACKGROUND

 Coagulopathy is a common serious complication of sepsis and septic shock; thus, its early detection and prompt management are important. For this purpose, recently the sepsis-induced coagulopathy (SIC) score was proposed.

METHODS

 We modified the SIC score for critically ill children with septic shock and evaluated its performance in comparison to several coagulopathy diagnostic scoring systems.

RESULTS

 Among 135 included patients, a significant number of patients were diagnosed with coagulopathy using different coagulopathy diagnostic criteria (up to 84.4% using the SIC score). The modified SIC score, comprising the pediatric sequential organ failure assessment (pSOFA) score, prothrombin time, and D-dimer, was used to diagnose SIC in 68 (50.4%) patients. It was well correlated with the pSOFA score and the International Society on Thrombosis and Haemostasis disseminated intravascular coagulation (DIC) score, as well as the SIC score (p < 0.001). The overall 28-day mortality rate was 18.7%. Patients with coagulopathy had worse clinical outcomes compared to those without coagulopathy. The modified SIC score was identified as an independent prognostic factor for 28-day mortality. The area under the receiver operating characteristic curve for performance of the modified SIC score to predict 28-day mortality evaluated was 0.771 (95% confidence interval: 0.658-0.883), better than those of the SIC and ISTH DIC scores (p < 0.05).

CONCLUSION

 Critically ill pediatric patients with septic shock frequently had concomitant coagulopathy. The modified SIC score showed good ability to predict 28-day mortality, suggesting its potential as a prognostic factor in these critically ill pediatric patients.

COVID-19 Associated Coagulopathy and Implications for its Treatment

The SARS-CoV-2 coronavirus (COVID-19) pandemic is due to lack of prior immunity and there is no certain management, regarding the complications of this viral illness. The target organ for COVID-19 infection are the lungs. Patients may develop acute lung injury that can be complicated by acute respiratory failure, as well as multiorgan failure. The pathophysiology of COVID-19 infection is characterized with inflammatory changes, associated with coagulopathy. Recent data suggests diffuse bilateral pulmonary inflammation observed in COVID-19 infection that is related to a novel pulmonary-specific vasculopathy, defined as pulmonary intravascular coagulopathy (PIC), distinct from disseminated intravascular coagulopathy (DIC). The coagulopathy associated with COVID-19 is distinguished by initial elevation of D-dimer and fibrin/fibrinogen degradation products. Abnormalities in prothrombin time (PT), partial thromboplastin time (APTT) and platelet counts are not common in the early stages of the infection. This suggests the early screening measurement of D-dimer and fibrinogen. The implications for COVID-19-associated-coagulopathy is the established thromboembolic prophylaxis and standard management for sepsis-induced coagulopathy or DIC. High levels of D-dimer are a marker of higher mortality risk. However, current studies do not show the common use of full therapeutical doses of anticoagulants, unless there are other clinical indications. Bleeding in COVID-19 infection is uncommon, even when a laboratory constellation for DIC is present. However, if it occurs, standard guidelines for DIC management should be followed.

COVID-19 associated atrial fibrillation: Incidence, putative mechanisms and potential clinical implications

Coronavirus disease 2019 (COVID-19) is a novel, highly transmittable and severe strain disease, which has rapidly spread worldwide. Despite epidemiological evidence linking COVID-19 with cardiovascular diseases, little is known about whether and how COVID-19 influences atrial fibrillation (AF), the most prevalent arrhythmia in clinical practice. Here, we review the available evidence for prevalence and incidence of AF in patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and discuss disease management approaches and potential treatment options for COVID-19 infected AF patients.

COVID-19 versus HIT hypercoagulability

A striking feature of COVID-19 is the high frequency of thrombosis, particularly in patients who require admission to intensive care unit because of respiratory complications (pneumonia/adult respiratory distress syndrome). The spectrum of thrombotic events is wide, including in situ pulmonary thrombosis, deep-vein thrombosis and associated pulmonary embolism, as well as arterial thrombotic events (stroke, myocardial infarction, limb artery thrombosis). Unusual thrombotic events have also been reported, e.g., cerebral venous sinus thrombosis, mesenteric artery and vein thrombosis. Several hematology abnormalities have been observed in COVID-19 patients, including lymphopenia, neutrophilia, thrombocytopenia (usually mild), thrombocytosis, elevated prothrombin time and partial thromboplastin times (the latter abnormality often indicating lupus anticoagulant phenomenon), hyperfibrinogenemia, elevated von Willebrand factor levels, and elevated fibrin d-dimer. Many of these abnormal hematologic parameters—even as early as the time of initial hospital admission—indicate adverse prognosis, including greater frequency of progression to severe respiratory illness and death. Progression to overt disseminated intravascular coagulation in fatal COVID-19 has been reported in some studies, but not observed in others. We compare and contrast COVID-19 hypercoagulability, and associated increased risk of venous and arterial thrombosis, from the perspective of heparin-induced thrombocytopenia (HIT), including the dilemma of providing thromboprophylaxis and treatment recommendations when available data are limited to observational studies. The frequent use of heparin—both low-molecular-weight and unfractionated—in preventing and treating COVID-19 thrombosis, means that vigilance for HIT occurrence is required in this patient population.

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HIT and COVID-19 are associated with a high risk of thrombosis (venous > arterial).

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HIT and COVID-19 both feature coagulation and “pancellular” activation.

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Therapeutic anticoagulation is indicated for HIT, but dosing unknown for COVID-19.

Sepsis-induced Coagulopathy and Disseminated Intravascular Coagulation

Coagulopathy, a common complication with sepsis, contributes to vascular injury and organ dysfunction. Early detection using diagnostic criteria for sepsis-induced coagulopathy is important to consider for potential clinical management.

COVID-19-Induced Cytokine Release Syndrome Associated with Pulmonary Vein Thromboses, Atrial Cardiomyopathy, and Arterial Intima Inflammation

Coronavirus disease 2019 (COVID-19) is a viral disease induced by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which may cause an acute respiratory distress syndrome (ARDS). First reports have shown that elevated levels of inflammatory cytokines might be involved in the development of organ dysfunction in COVID-19. Here, we can present a case of cytokine release syndrome induced by SARS-CoV-2 causing multiorgan failure and death. Of note, we can report on pulmonary vein thromboses as potential source of cerebrovascular embolic events. Furthermore, we present a specific form of an isolated inflammatory atrial cardiomyopathy encompassing atrial myocardium, perivascular matrix, as well as atrial autonomic nerve ganglia, causing atrial fibrillation, sinus node arrest, as well as atrial clot formation in the right atrial appendage. An associated acute glomerulonephritis caused acute kidney failure. Furthermore, all the described pathologies of organs and vessels were associated with increased local expression of interleukin-6 and monocyte chemoattractant protein-1 (MCP-1). This report provides new evidence about fatal pathologies and summarizes the current knowledge about organ manifestations observed in COVID-19.

COVID-19 and its implications for thrombosis and anticoagulation

Severe acute respiratory syndrome coronavirus 2, coronavirus disease 2019 (COVID-19)-induced infection can be associated with a coagulopathy, findings consistent with infection-induced inflammatory changes as observed in patients with disseminated intravascular coagulopathy (DIC). The lack of prior immunity to COVID-19 has resulted in large numbers of infected patients across the globe and uncertainty regarding management of the complications that arise in the course of this viral illness. The lungs are the target organ for COVID-19; patients develop acute lung injury that can progress to respiratory failure, although multiorgan failure can also occur. The initial coagulopathy of COVID-19 presents with prominent elevation of D-dimer and fibrin/fibrinogen-degradation products, whereas abnormalities in prothrombin time, partial thromboplastin time, and platelet counts are relatively uncommon in initial presentations. Coagulation test screening, including the measurement of D-dimer and fibrinogen levels, is suggested. COVID-19–associated coagulopathy should be managed as it would be for any critically ill patient, following the established practice of using thromboembolic prophylaxis for critically ill hospitalized patients, and standard supportive care measures for those with sepsis-induced coagulopathy or DIC. Although D-dimer, sepsis physiology, and consumptive coagulopathy are indicators of mortality, current data do not suggest the use of full-intensity anticoagulation doses unless otherwise clinically indicated. Even though there is an associated coagulopathy with COVID-19, bleeding manifestations, even in those with DIC, have not been reported. If bleeding does occur, standard guidelines for the management of DIC and bleeding should be followed.

Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China

Thrombocytopenia is a common complication of critical care patients. The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia. Therefore, the Critical Care Medicine Committee of Chinese People's Liberation Army (PLA) worked with Chinese Society of Laboratory Medicine, Chinese Medical Association to develop this consensus to provide guidance for clinical practice. The consensus includes five sections and 27 items: the definition of thrombocytopenia, etiology and pathophysiology, diagnosis and differential diagnosis, treatment and prevention.

Thrombomodulin in disseminated intravascular coagulation and other critical conditions-a multi-faceted anticoagulant protein with therapeutic potential

Thrombomodulin plays a vital role in maintaining intravascular patency due to its anticoagulant, antiinflammatory, and cytoprotective properties. However, under pathological conditions such as sepsis and systemic inflammation, endothelial thrombomodulin expression is downregulated and its function impaired. As a result, administering thrombomodulin represents a potential therapeutic modality. Recently, the effect of recombinant thrombomodulin administration in sepsis-induced coagulopathy was evaluated in a randomized controlled study (SCARLET). A 2.6% 28-day absolute mortality reduction (26.8% vs. 29.4%) was reported in 800 patients studied that was not statistically significant; however, a post hoc analysis revealed a 5.4% absolute mortality reduction among the patients who fulfilled the entry criterion at baseline. The risk of bleeding did not increase compared to placebo control. Favorable effects of thrombomodulin administration have been reported not only in sepsis-induced coagulopathy but also in disseminated intravascular coagulations with various backgrounds. Interestingly, beneficial effects of recombinant thrombomodulin in respiratory, renal, and cardiovascular diseases might depend on its anti-inflammatory mechanisms. In this review, we summarize the accumulated knowledge of endogenous as well as recombinant thrombomodulin from basic to clinical aspects and suggest future directions for this novel therapeutic agent.

Advance in the Management of Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation

Coagulopathy commonly occurs in sepsis as a critical host response to infection that can progress to disseminated intravascular coagulation (DIC) with an increased mortality. Recent studies have further defined factors responsible for the thromboinflammatory response and intravascular thrombosis, including neutrophil extracellular traps, extracellular vesicles, damage-associated molecular patterns, and endothelial glycocalyx shedding. Diagnosing DIC facilitates sepsis management, and is associated with improved outcomes. Although the International Society on Thrombosis and Haemostasis (ISTH) has proposed criteria for diagnosing overt DIC, these criteria are not suitable for early detection. Accordingly, the ISTH DIC Scientific Standardization Committee has proposed a new category termed “sepsis-induced coagulopathy (SIC)” to facilitate earlier diagnosis of DIC and potentially more rapid interventions in these critically ill patients. Therapy of SIC includes both treatment of the underlying infection and correcting the coagulopathy, with most therapeutic approaches focusing on anticoagulant therapy. Recently, a phase III trial of recombinant thrombomodulin was performed in coagulopathic patients. Although the 28-day mortality was improved by 2.6% (absolute difference), it did not reach statistical significance. However, in patients who met entry criteria for SIC at baseline, the mortality difference was approximately 5% without increased risk of bleeding. In this review, we discuss current advances in managing SIC and DIC.

Sepsis-associated disseminated intravascular coagulation and its differential diagnoses

Disseminated intravascular coagulation (DIC) is a common complication in sepsis. Since DIC not only promotes organ dysfunction but also is a strong prognostic factor, its diagnosis at the earliest possible timing is important. Thrombocytopenia is often present in patients with DIC but can also occur in a number of other critical conditions. Of note, many of the rare thrombocytopenic diseases require prompt diagnoses and specific treatments. To differentiate these diseases correctly, the phenotypic expressions must be considered and the different disease pathophysiologies must be understood. There are three major players in the background characteristics of thrombocytopenia: platelets, the coagulation system, and vascular endothelial cells. For example, the activation of coagulation is at the core of the pathogenesis of sepsis-associated DIC, while platelet aggregation is the essential mechanism in thrombotic thrombocytopenic purpura and endothelial damage is the hallmark of hemolytic uremic syndrome. Though each of the three players is important in all thrombocytopenic diseases, one of the three dominant players typically establishes the individual features of each disease. In this review, we introduce the pathogeneses, symptoms, diagnostic measures, and recent therapeutic advances for the major diseases that should be immediately differentiated from DIC in sepsis.