Xu Weiwei, Li Ming, Cui Guangqing, Wang Ruilan
Department of Critical Care Medicine, the First People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 201620, China.
Department of Critical Care Medicine, Dongtai Hospital Affiliated to Nantong University, Dongtai 224200, Jiangsu, China. Xu Weiwei is working on the Department of Critical Care Medicine, Dongtai Hospital Affiliated to Nantong University, Dongtai 224200, Jiangsu, China. Corresponding author: Wang Ruilan, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2021 May;33(5):621-625. doi: 10.3760/cma.j.cn121430-20201126-00731.
Sepsis is caused by the imbalance of the host body's response to infection, which causes life-threatening organ dysfunction. Disorders of blood coagulation play a very important role in the development of sepsis. In sepsis, the body's coagulation system is activated, leading to hypercoagulability, while the anticoagulation mechanism is significantly inhibited, causing a large number of microthrombi to form, and disseminated intravascular coagulation (DIC) may occur. Although there are obvious controversies about the anticoagulation treatment of sepsis at home and abroad, we cannot deny the significance of anticoagulation treatment in sepsis. Only appropriate anticoagulation can effectively reduce the mortality in septic DIC, septic shock and high-risk population, and ultimately effectively reduce the occurrence of multiple organ dysfunction syndrome. The sepsis-induced coagulation dysfunction (SIC) score is currently used internationally to guide anticoagulation. SIC score is optimized based on the International Society on Thrombosis and Haemostasis (ISTH) overt DIC score and Sepsis-3, including platelet, international normalized ratio (INR) and sequential organ failure assessment (SOFA). The SIC score can sensitively monitor sepsis-induced coagulation dysfunction. When the SIC score is ≥ 4, it is the best timing to initiate anticoagulation therapy. At present, the internationally recommended anticoagulant drugs include antithrombin (AT), thrombomodulin (TM), tissue factor pathway inhibitor (TFPI), heparin, etc., while the domestically recommended anticoagulant drugs are only unfractionated heparin and low molecular weight heparin. Before using anticoagulant drugs, it is necessary to evaluate the possibility of bleeding and thrombosis in the patients. At the same time, it is necessary to pay attention to the patient's primary disease. Try to adopt the treatment strategy of transitioning from unfractionated heparin to low molecular weight heparin without obvious anticoagulation contraindications.
脓毒症是由宿主机体对感染的反应失衡所致，可导致危及生命的器官功能障碍。凝血功能紊乱在脓毒症的发展过程中起着非常重要的作用。在脓毒症中，机体的凝血系统被激活，导致血液高凝状态，而抗凝机制则受到显著抑制，致使大量微血栓形成，可能发生弥散性血管内凝血（DIC）。尽管国内外对于脓毒症的抗凝治疗存在明显争议，但我们不能否认抗凝治疗在脓毒症中的重要意义。只有恰当的抗凝治疗才能有效降低脓毒症DIC、脓毒症休克及高危人群的死亡率，最终有效减少多器官功能障碍综合征的发生。目前国际上采用脓毒症诱导的凝血功能障碍（SIC）评分来指导抗凝治疗。SIC评分是在国际血栓与止血学会（ISTH）显性DIC评分和脓毒症-3的基础上优化而来，包括血小板、国际标准化比值（INR）和序贯器官衰竭评估（SOFA）。SIC评分能够灵敏地监测脓毒症诱导的凝血功能障碍。当SIC评分≥4时，是启动抗凝治疗的最佳时机。目前，国际上推荐的抗凝药物包括抗凝血酶（AT）、血栓调节蛋白（TM）、组织因子途径抑制物（TFPI）、肝素等，而国内推荐的抗凝药物仅有普通肝素和低分子肝素。在使用抗凝药物之前，有必要评估患者出血和血栓形成的可能性。同时，需要关注患者的基础疾病。在无明显抗凝禁忌证的情况下，尽量采用从普通肝素过渡到低分子肝素的治疗策略。
