1. Sepsis and coagulation Christian Fenger-Eriksen Center for Haemophilia and Thrombosis, Department of Anaesthesiology, Aarhus University Hospital, Denmark chfen@dadlnet.dk

2. Outline of presentation  Normal Haemostasis o Coagulopathy of sepsis o Disseminated Intravascular Coagulation o Mechanism o Diagnosis o Treatment o Dilutional coagulopathy o Hyperfibrinolysis o Anaemia o Acidose/Hypotermi

3. The Haemostatic System anno 2009 Primary haemostasis = von Willebrand Factor = platelet = activated platelet = fibrinogen

4. The Haemostatic System anno 2009 Secondary haemostasis Tissue factor-FVIIa Thrombin Fibrinogen Fibrin FVIIIa-FIXa Intrinsic tenase FVa-FXa Prothrombinnase FX FXa FXIII

5. Thrombophilia Bleeding tendency Healthy Haemostasis Balance versus imbalance

6. Thrombophilia DIC Tissue factor induced activation Bedrest Cancer Brain damage Bleeding tendency DIC Consumption Hyperfibrinolyse Colloids Anaemia Hypotermia Haemostasis Thrombophilia versus bleeding

7. Clinical picture Sepsis

8. Coagulopathy of sepsis Inflammation and coagulation  Close relation between inflammtory response and coagulation activation  Monocytes and microparticles express tissue factor  LPS Activates FXII Interaction with endothelial cells – Tissue factor Activates platelets  Result: Imbalance between intravascular fibrin formation and its removal

9. Coagulopathy of sepsis Activation Tissue factor-FVIIa Thrombin Fibrinogen Fibrin Fibrinogen split products

10. Coagulopathy of sepsis Regulatory mechanism of activation  Antithrombin,  The protein C system,  Tissue factor pathway inhibitor

11. Coagulopathy of sepsis Systemic anticoagulation ThrombinFibrinTissue factor-FVIIa Activated Protein C Antithrombin – TAT Rapid clearance of TAT Antithrombin negative acute phase protein TFPI Plasma/endothelial cells Thrombomodulin

12. Dissemineret intravascular coagulation Definition  Intravascular activation and imbalance of inhibition and fibrinolysis  Microthrombosis Brain (delirium/coma) Skin (necrosis) Kidney (oliguri/renal failure) Lungs (ARDS) Multi Organ Dysfunction Syndrome Bleeding

13. Dissemineret intravascular coagulation Diagnose  Clinical diagnose  Biochemistry: Activation:  Platelets low/decreasing  FII, VII and FX low  Fibrinogen low/decreasing (acute phase) Fibrinolysis:  D-dimer high Consumption of inhibitors:  Antithrombin low  Protein C normal  TAT high

14. DIC score I Overt DIC  Does the patient have an underlying disorder known to be associated with overt DIC, YES? Platelet count (10*9/l): (>100 = 0; 50-100 = 1;<50 = 2) Fibrin-related marker: (No increase = 0; Moderate increase = 2; Strong increase = 3) Prolonged prothrombin time: ( 6 s = 2) Fibrinogen: (>1.0 g/l = 0; <1.0 g/l: 1)  If the sum is ≥5, the patient status is compatible with overt DIC.

15. XII XIIa XI XIa IX IXa X Xa Prothrombin Thrombin Fibrinogen Fibrin TF VIIa TF VII Va VIIIa The coagulation cascade Secondary haemostasis Intrinsic pathwayExtrinsic pathway DIC-screen Platelets APTT PT relativ Thrombintime Fibrin d-dimer Antithrombin Fibrinogen PTrelativ APTT

16. Heparin induced thrombocytopenia  Beware: Isolated Thrombocytopenia without other affection Thrombosis during heparing treatment  Incidens: UFH; 0.5-5% LMH; 0,05-0,5%  Patogenesis: Antibody formation against platelets (activation) + tissue factor release from monocytes 5-10 days after institution of treatment

17. Heparin induced thrombocytopenia  Diagnose: Isolated thrombocytopenia HIT antibody detection (2-5 days) HIT scoring system  Treatmens: Stop heparin treatment Thrombin inhibitor  Argatroban (Novastan) Christoffersen C., Ugeskr Læger 2009;171(8):612

18. Coagulopathy of sepsis Treatment ThrombinFibrinTissue factor-FVIIa Activated Protein C Antithrombin – TAT Rapid clearance of TAT Antithrombin negative acute phase protein TFPI Plasma/endothelial cells Thrombomodulin

19. Antithrombin  Small clinical trials: improvement of a DIC score shortening of the duration of DIC improvement in organ function  Randomized, controlled clinical trial, 2314 patients with severe sepsis (Kybersept trial9 Identical mortality between treatment with antithrombin for 4 days versus placebo Trend; Decreased mortality in subgroup of patients who did not receive heparin M Levi M, Schouten M, van der Poll T. Semin Thromb Hemost. 2008 Nov;34(8):742-6. Review.

20. Tissue factor pathway inhibitor  TFPI has been shown to attenuate IL-6 and IL-8 release in an animal model  A large RCT failed to show a reduced mortality in patients with severe sepsis Levi M Crit Care. 2005;9(6):624-5.

21. Activated Protein C Xigris  Recombinant protein  Indication: Severe sepsis MODS  Evidens: 28 day mortality APC vs. Placebo Mortality 24,7% (APC) vs. 30,8% (Placebo) E Tønnesen Ugeskr Læger 2004;166(11):1002 Bernard GR, Vincent JL, Laterre PF et al. N Engl J Med 2001;344:699-709.

22. Activated Protein C Xigris  Drug approval based on a single study  Side effects: Serious bleeding events APC (3.5%) vs. placebo (2.0%), p=0.06  First part of study 720 patients inrolled – no effect of APC treatment  Monitorering / duration of treatment  Mode of action Eichacker PQ. Crit Care Med. 2003 Jan;31(1 Suppl):S94-6. Review. Costa V et al.BMC Anesthesiol. 2007 Jun 25;7:5.

23. Dissemineret intravascular coagulation Treatment  Treat underlying disease  Fresh frozen plasma  Platelets pool – only thrombocytopenia induced bleeding  Fibrinogen concentrate – only during massive bleeding and afibrinogenaemia  Xigris  Consult: Local coagulation lab.

24. Hyperfibrinolysis  Increased breakdown of the clot formed  Induced by Release of fibrinolytic agents from damaged endothelial cells Hypoperfusion  Massive bleeding  Obstetric  Urology  Severe trauma (ISS <25)

25. Hyperfibrinolysis  Treatment; tranexamic acid 15 mg/kg Remember to substitute consumptioned fibrinogen  CRASH II study 20,000 trauma patients Ongoeing bleeding or significant risk for bleeding RCT; tranexamic acid or placebo End-points; Death and transfusion requirements Brohi K et al J Trauma. 2008 May;64(5):1211-7; WWW.CRASH2.LSHTM.AC.UK

26. Anaemia Changes flow conditions Haematocrit correlates inverse with bleeding time Valeri R et al. Transfusion. 2001;41:(8):977-983

27. Dilutional cogulopathy Definition Ongoing Bleeding + Intravenously fluid resuscitation = Haemodilution

28. Dilutional coagulopathy Crystalloids vs colloids Porcine model of bleeding –30 pigs, removal of 60% of blood volume –Substitution with: Hypertonic saline + HES 200/0.65 (HyperHaes) HES 130/0.4 (Voluven) Gelatine (Gelofusin) –Hepatic incision

29. Dilutional coagulopathy Crystalloids vs colloids, Blood loss Hypertonic saline + HES 200/0.65 (HyperHaes) –725 (375 - 900) ml HES 130/0.4 (Voluven) –1600 (1500 - 1800) ml Gelatine (Gelofusin) –1625 (1275 -1950) ml

30. Colloid induced coagulopathy Aquired fibrinogen deficiency –Dys-functional fibrinogen with compromised polymerization induced by hydroxyethyl starch plasma expanders –Reduces clot strength –Increases bleeding Fries et al. Br J Anaest 95(2):172-7 (2005) Fenger-Eriksen et al. Br J Anaest 94(3)324-29 (2005) E de Jonge et al. Crit Care Med 2001 Vol 29 1261-67 Haas T et al Anesth Analg 2008 Apr; 106(4):1078-86 Hiippala ST et al., Anesth Analg. 1995 Aug;81(2):360-5

31. Coagulopathy of the bleeding patient Dilution Fenger-Eriksen C et al. J Thromb Haemost 2009 N=20, *significant different from baseline, ** expected Baseline30% HaemodilutionRelative decrease % Haematocrit 0.43 ± 0.030.29 ± 0.02- 32 ± 5 Platelet count (10*9L) 248 ± 65181 ± 50*- 27± 5 P-fibrinogen (µmol/L) 9.5 ± 1.95.1 ± 0.8*- 44 ± 4.4** Trombin Generation (nM*min) 1471 ± 3091532 ± 247+ 3.8 ± 11

32. Postpartum hemorrhage Fibrinogen and bleeding Fibrinogen level significantly associated with the worsening of bleeding Women requiring uterotonic prostaglandin-infusion – Fibrinogen levels <2 g/l – Positive predictive value for PPH at 100% – Fibrinogen levels >4 g/l – Negative predictive value at 79% B Charbit et al. J Thromb Haemost 2007;5:266-273

33. Fibrinogen substitution during massive bleeding  43 patients recieving fibrinogen concentrate (Haemocomplettan) at Skejby Hospital,  Hypofibrinogenaemia and massive bleeding Increases fibrinogen Improves PT, APTT Reduces bleeding Fenger-Eriksen C et al. Br J Anaesth 2008 Dec;101(6):769-73

34. Dilutional coagulopathy Are crystalloids better? Probably yes regarding coagulation Large volumina are required –Hyperchloremic acidosis Renal impairment Secondary impairment of coagulation

35. Thrombin generation Acidose and hypothermia Martini el al J Trauma 2005(58-5) 1002-1010

36. Sepsis and coagulation Conclusion Close relation between inflammtory response and coagulation activation o Activation o Imbalance of regulatory mechanism and fibrinlolysis o Dysfunctional fibrinogen from colloids o Acidosis o Hypothermia o Hyperfibrinolysis o Anaemia o Electrolyte disturbances

37. Blood transfusion Circulation 2007;116:2544–52 Murphy GJ et al. Circulation 2007;116:2544–52

38. Blood transfusion Am J Cardiol 2008;102:115–119 Aronson D et al. Am J Cardiol 2008;102:115–119

39. N Engl J Med 2008;358:1229–39 Koch CG et al. N Engl J Med 2008;358:1229–39