Journal of Antimicrobial Chemotherapy, Vol 41, 17-24, Copyright © 1998 by The British Society for Antimicrobial Chemotherapy
EF Mammen
Haematological changes in the septic patient are, primarily, neutropenia or
neutrophilia, thrombocytopenia and disseminated intravascular coagulation
(DIC). Thrombocytopenia frequently arises from DIC although inhibition of
thrombopoiesis or immunological platelet damage also occur. DIC contributes
to bleeding and microvascular thrombosis, leading to multiple organ
failure. Tissue factor release, primarily mediated by tumour necrosis
factor, activates the clotting system; fibrinolysis is initially activated,
but later becomes inhibited by the release of plasminogen-activator
inhibitor (PAI-1), further fostering multiple organ failure. Most septic
patients have compensated, chronic DIC, detectable by assays of molecular
markers; the earliest signs are already found during the systemic
inflammatory response syndrome. Compensated DIC later becomes decompensated
with rapid consumption of factors including inhibitors such as antithrombin
III (AT III) and proteins C and S. AT III concentrations of < 60-70% of
the normal values predict outcome. Management of DIC must address the
underlying disease, interrupt the activated haemostasis system and replace
consumed coagulation constituents. Interruption of haemostasis with heparin
may be attempted, but bleeding may worsen. Administration of a natural
anticoagulant, such as AT III, may arrest clotting without concomitant risk
of bleeding. In several animal models of DIC, AT III concentrates shortened
the duration of DIC and reduced multiple organ failure and mortality.
Similar benefits have been reported in early studies of patients with DIC,
especially in the absence of sepsis. Studies are under way to determine
whether outcome will improve if patients with sepsis are treated before the
development of shock and plasma AT III concentrations are maintained at
100-150% of normal.
ORIGINAL ARTICLES
The haematological manifestations of sepsis
Wayne State University School of Medicine, Mott Center, Detroit, MI 48201, USA.
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