Hamostaseologie 2024; 44(S 01): S94
DOI: 10.1055/s-0044-1779204
Abstracts
Topics
T-15. Perioperative haemostasis

Fibrinolysis resistance in a patient with Streptococcus pyogenes associated septic shock and necrotizing fasciitis.

K. M. Hofmann
1   Jena University hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
,
M. Brauer
1   Jena University hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
,
A. Kortgen
1   Jena University hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
,
M. Bauer
1   Jena University hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
› Author Affiliations
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Introduction Sepsis- induced coagulopathy (SIC) is a serious complication in patients with sepsis and septic shock. In an observational survay conducted in japan 29 percent of patients treated for sepsis developed SIC.

Systemic inflammation due to host invasion by pathogens is responsible for systemic coagulation activation.SIC is part of a host defence mechanism , leading to a inbalance in clot generation and fibrinolysis. Diffuse activation of endothelium by proinflammatory cytokines, leucocytes and other proteins create a prothrombotic state with excessive thrombin generation, resulting in an insoluble fibrin network, microvascular thrombosis and multiple organ dysfunction. Concomitantly, fibrinolysis can be impaired by increased production and activation of inhibitors such as PAI-1 and TAFI, as well as reduced t- PA.

Method A 66-year-old female patient was admitted to the emergency room with fever, chills and pain in her right arm after an insect bite. After hospitalization, the patient developed fulminant septic shock with severe ARDS, high-dose vasopressor therapy and multiorgan dysfunction. CT scan showed soft tissue infection of the right axilla and upper arm. To monitor SIC, we performed daily standard coagulation tests. In addition, we performed viscoelastic tests including TPA test to monitor fibrinolysis.

Results We treated with local debridement, fasciectomy, penicillin G and clindamycin for confirmed Streptococcus pyogenes infection, as well as guideline- based supportive sepsis therapy. Additionally we used antithrombin concentrate and low-dose heparin to treat the accompanying SIC and lysis resistance with a target range for antithrombin of 70 to 80 percent. Platelet count, antithrombin and Quick were significantly decreased, while D-dimer and aPTT were increased. Platelet count fell to a minimum of 19 gpt/l. If the patient was in an overall prothrombotic state, we refrained from platelet transfusion if there was no clinical bleeding and resistance to lysis. Lysis resistance persisted for a total of 5 days. On day 5, the platelet counts increased spontaneously and antithrombin no longer needed to be substituted. Quick value normalized, the D-dimers decreased. The patient stabilized clinically [1] [2] [3] [4] [5].

Conclusion SIC represents a serious complication of sepsis and septic shock. Some of these patients develop resistance to fibrinolysis. Limited data suggest resistance of fibrinolysis correlates with higher markers of cellular damage, higher severity score and worse outcome. The treatment of fibrinolysis resistance is still unclear. In addition to causal and supportive sepsis therapy, pathophysiological considerations discuss a continuous low-dose administration of rt-PA. The ClotPro TPA test represents a way to monitor fibrinolysis resistance in critically ill patients bedside. More studies are needed to investigate monitoring and treatment of fibrinolysis resistance in critically ill patients.



Publication History

Article published online:
26 February 2024

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