D-dimer Correlates With Proinflammatory Cytokine Levels and Outcomes in Critically Ill Patients

Shorr, Andrew F.; Thomas, Stephen J.; Alkins, Stephan A.; Fitzpatrick, Thomas M.; Ling, Geoffrey

doi:10.1378/chest.121.4.1262

Cited by 161 publications

(118 citation statements)

References 33 publications

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“…are detectable in 42% of a consecutive series of intensive care patients, in 80% of trauma patients and in 99% of patients with sepsis [10][11][12]. Low levels of coagulation inhibitors, such as antithrombin and protein C, are found in 40% to 60% of trauma patients and 90% of sepsis patients [12,13].…”

Section: Incidence and Relevancementioning

confidence: 99%

Coagulation Abnormalities in Critically Ill Patients

Levi¹,

Opal²

2016

Surgical Intensive Care Medicine

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Many critically ill patients develop hemostatic abnormalities, ranging from isolated thrombocytopenia or prolonged global clotting tests to complex defects, such as disseminated intravascular coagulation. There are many causes for a deranged coagulation in critically ill patients and each of these underlying disorders may require specific therapeutic or supportive management. In recent years, new insights into the pathogenesis and clinical management of many coagulation defects in critically ill patients have been accumulated and this knowledge is helpful in determining the optimal diagnostic and therapeutic strategy. IntroductionCoagulation abnormalities are commonly found in critically ill patients. A myriad of altered coagulation parameters are readily measurable, such as thrombocytopenia, prolonged global coagulation times, reduced levels of coagulation inhibitors, or high levels of fibrin split products. Prompt and proper identification of the underlying cause of these coagulation abnormalities is required, since each coagulation disorder necessitates very different therapeutic management strategies. This article reviews the most frequently occurring coagulation abnormalities in patients in the intensive care unit, with an emphasis on differential diagnosis, underlying molecular and pathogenetic pathways, and appropriate diagnostic and therapeutic interventions. Incidence and relevanceThe incidence of thrombocytopenia (platelet count <150 × 10 9 /l) in critically ill medical patients is 35% to 44% [1][2][3]. A platelet count of <100 × 10 9 /l is seen in 20% to 25% of patients, whereas 12% to 15% of patients have a platelet count <50 × 10 9 /l. In surgical and trauma patients, the incidence of thrombocytopenia is higher, with 35% to 41% of patients having less than 100 × 10 9 /l platelets [4,5]. Typically, the platelet count decreases during the patient's first four days in the intensive care unit (ICU) [6].The primary clinical relevance of thrombocytopenia in critically ill patients is related to an increased risk of bleeding. Indeed, severely thrombocytopenic patients with platelet counts of <50 × 10 9 /l have a 4-to 5-fold higher risk for bleeding compared to patients with higher platelet counts [1,3]. The risk of intracerebral bleeding in critically ill patients during intensive care admission is relatively low (0.3% to 0.5%), but 88% of patients with this complication have platelet counts below 100 × 10 9 /l [7]. Moreover, a decrease in platelet count may indicate ongoing coagulation activation, which contributes to microvascular failure and organ dysfunction. Regardless of the cause, thrombocytopenia is an independent predictor of ICU mortality in multivariate analyses (relative risk, 1.9 to 4.2 in various studies) [1,3,4]. Several studies show that the severity of thrombocytopenia in critically ill patients is inversely related to survival. In particular, sustained thrombocytopenia over more than 4 days after ICU admission or a drop in platelet count of >50% during ICU stay correlates with a 4...

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Section: Incidence and Relevancementioning

confidence: 99%

Coagulation Abnormalities in Critically Ill Patients

Levi¹,

Opal²

2016

Surgical Intensive Care Medicine

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“…35,36 The reported low specificity rate is expected because D-dimer levels are elevated in such different conditions as disseminated intravascular coagulation and sepsis. 37 Elevated D-dimer levels are found in patients after major abdominal surgery and especially when its course is complicated by a septic event. 37,38 In our series, elevated D-dimer levels were found in patients with septic collections, prolonged stays in intensive care, or deep vein thrombosis.…”

Section: Commentmentioning

confidence: 99%

Prospective Study of the Incidence and Risk Factors of Postsplenectomy Thrombosis of the Portal, Mesenteric, and Splenic Veins

Stamou

Toutouzas²,

Kekis³

et al. 2006

Arch Surg

179

118

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“…In this situation, the localized tissue infection is unlikely to be the cause of the marked D-dimer elevation. In any event, D-dimer levels tend to be lower in sepsis unless severe multiorgan failure supervenes (13,14).…”

Section: Discussionmentioning

confidence: 98%

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

Ibebuogu

Salah

Malhotra

et al. 2008

Canadian Journal of Cardiology

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A trial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age (1,2). Peripheral thromboembolism and ischemic stroke contribute significantly to the observed mortality and morbidity rates. AF contributes to 15% to 20% of all strokes (1,3), and emboli arise predominantly from the left atrial appendage (LAA) (4). Hence, there is a need to exclude atrial thrombi before cardioversion in symptomatic AF. A recent large, randomized controlled trial has shown that negative transesophageal echocardiography (TEE) results may obviate the need for prolonged anticoagulation before cardioversion, with no significant difference in embolic events compared with conventional therapy (5). Because of the complex multilobed configuration of the LAA and the minute size of clinically significant thrombi, there are inherent limitations in using a nontomographic technique for visualization of the LAA. Using the two-dimensional beam of TEE in visualizing the three-dimensional anatomy of the LAA is analogous to using a searchlight to visualize the entire roof of a cave, which is technically difficult to achieve completely. Studies have shown that embolism may presumably occur after cardioversion of AF, despite apparent exclusion of a pre-existing atrial thrombus by TEE (6). Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombus (7) and may improve the evaluation of a patient with AF before cardioversion. CASE PRESENTATIONA 56-year-old man eight years post-renal transplant and four years post-coronary artery bypass surgery, as well as a history of adequately treated, methicillin-resistant Staphylococcus epidermidis bacteremia, CASE REPORT ©2008 Pulsus Group Inc. All rights reserved Atrial fibrillation (AF) is a common arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age. Peripheral thromboembolism contributes significantly to the observed morbidity and mortality. Symptomatic AF, before cardioversion to normal sinus rhythm, requires either exclusion of atrial thrombi using transesophageal echocardiography (TEE) or the conventional use of three weeks of adequate anticoagulation. The exclusion of atrial thrombi by TEE, a nontomographic technique but comparable with conventional treatment of AF in outcomes, has inherent limitations due to the complex three-dimensional multilobed anatomy of the left atrial appendage, where the majority of atrial thrombi arise. Also, the conventional treatment of three weeks of therapeutic anticoagulation before cardioversion reportedly does not always eliminate atrial thrombi. Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombosis and, hence, may improve the evaluation of a patient with A...

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D-dimer Correlates With Proinflammatory Cytokine Levels and Outcomes in Critically Ill Patients

Cited by 161 publications

References 33 publications

Coagulation Abnormalities in Critically Ill Patients

Coagulation Abnormalities in Critically Ill Patients

Prospective Study of the Incidence and Risk Factors of Postsplenectomy Thrombosis of the Portal, Mesenteric, and Splenic Veins

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

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