严重脓毒症患者心房颤动抗凝治疗的挑战。

Challenges of anticoagulation for atrial fibrillation in patients with severe sepsis.

机构信息

University of California Irvine, Irvine, CA, USA.

出版信息

Ann Pharmacother. 2013 Oct;47(10):1266-71. doi: 10.1177/1060028013500938.

DOI:10.1177/1060028013500938

PMID:24259690

Abstract

BACKGROUND

Although numerous studies have shown that anticoagulation of nonvalvular atrial fibrillation (AF) significantly decreases the risk of stroke, anticoagulating critically ill patients in the intensive care unit (ICU) poses many challenges and the benefits have not been determined.

OBJECTIVE

To assess the safety and efficacy of anticoagulation in AF patients with sepsis. Ascertaining the incidence of complications associated with anticoagulation therapy, such as bleeding, can optimize patient care.

METHODS

This was a retrospective observational study to assess the incidence of stroke and anticoagulation-related complications (eg, bleeding, heparin-induced thrombocytopenia) in AF patients with severe sepsis. This study was undertaken in a surgical/medical ICU of a teaching, community-based hospital. A total of 115 patients with AF who were admitted with a diagnosis of sepsis were included in the study.

RESULTS

Among 115 patients (mean age 81 ± 9.5 years and CHADS2 [congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke] score 3.17 ± 1.20), 80 (69.6%) did not receive anticoagulation treatment during their hospitalization and none of these patients developed a stroke. Anticoagulation-related complications occurred more often in the group who received anticoagulation (8.6% [3/35] vs 0%, P = .008). In the anticoagulated group, a majority of the patients were within therapeutic range less than 50% of the time during their ICU stay. There was no statistically significant difference in survival rates during their hospitalization (66.2% [53/80] for the non-anticoagulated group vs 74.3% [26/35] in the anticoagulated group, P = .392).

CONCLUSION

Administration of anticoagulation for elderly patients with a CHADS2 score at 2 or more in the setting of sepsis can be associated with an increased risk of anticoagulation-related complications (eg, bleeding, heparin-induced thrombocytopenia). Managing and targeting a therapeutic goal with warfarin therapy in critically ill patients with sepsis is challenging. Further studies are necessary to provide appropriate recommendations in this setting.

摘要

背景

尽管大量研究表明，非瓣膜性心房颤动（AF）的抗凝治疗可显著降低中风风险，但在重症监护病房（ICU）中对危重症患者进行抗凝治疗存在诸多挑战，且其获益尚未确定。

目的

评估 AF 合并脓毒症患者抗凝治疗的安全性和有效性。确定与抗凝治疗相关的并发症（如出血）的发生率，可以优化患者的治疗。

方法

这是一项回顾性观察性研究，旨在评估严重脓毒症合并 AF 患者中发生中风和抗凝相关并发症（如出血、肝素诱导的血小板减少症）的发生率。该研究在一所教学型社区医院的外科/内科 ICU 中进行。共纳入 115 例因 AF 合并脓毒症住院的患者。

结果

在 115 例患者（平均年龄 81 ± 9.5 岁，CHADS2[充血性心力衰竭、高血压、年龄＞75 岁、糖尿病、中风]评分为 3.17 ± 1.20）中，80 例（69.6%）患者在住院期间未接受抗凝治疗，且这些患者均未发生中风。接受抗凝治疗的患者中，抗凝相关并发症的发生率更高（8.6%[3/35] vs. 0%，P=.008）。在抗凝治疗组中，大多数患者在 ICU 住院期间只有不到 50%的时间处于治疗范围内。两组患者的住院期间生存率无统计学差异（非抗凝组为 66.2%[53/80]，抗凝组为 74.3%[26/35]，P=.392）。