Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan.
Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan.
Shock. 2024 Jan 1;61(1):89-96. doi: 10.1097/SHK.0000000000002269. Epub 2023 Nov 15.
Background: Although coagulopathy is often observed in acute respiratory distress syndrome (ARDS), its clinical impact remains poorly understood. Objectives: This study aimed to clarify the coagulopathy parameters that are clinically applicable for prognostication and to determine anticoagulant indications in sepsis-induced ARDS. Method: This study enrolled patients with sepsis-derived ARDS from two nationwide multicenter, prospective observational studies. We explored coagulopathy parameters that could predict outcomes in the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) cohort, and the defined coagulopathy criteria were validated in the Sepsis Prognostication in Intensive Care Unit and Emergency Room-Intensive Care Unit (SPICE-ICU) cohort. The correlation between anticoagulant use and outcomes was also evaluated. Results: A total of 181 patients with sepsis-derived ARDS in the FORECAST study and 61 patients in the SPICE-ICU study were included. In a preliminary study, we found the set of prothrombin time-international normalized ratio ≥1.4 and platelet count ≤12 × 10 4 /μL, and thrombocytopenia and elongated prothrombin time (TEP) coagulopathy as the best coagulopathy parameters and used it for further analysis; the odds ratio (OR) of TEP coagulopathy for in-hospital mortality adjusted for confounding was 3.84 (95% confidence interval [CI], 1.66-8.87; P = 0.005). In the validation cohort, the adjusted OR for in-hospital mortality was 32.99 (95% CI, 2.60-418.72; P = 0.002). Although patients without TEP coagulopathy showed significant improvements in oxygenation over the first 4 days, patients with TEP coagulopathy showed no significant improvement (ΔPaO 2 /FiO 2 ratio, 24 ± 20 vs. 90 ± 9; P = 0.026). Furthermore, anticoagulant use was significantly correlated with mortality and oxygenation recovery in patients with TEP coagulopathy but not in patients without TEP coagulopathy. Conclusion: Thrombocytopenia and elongated prothrombin time coagulopathy is closely associated with better outcomes and responses to anticoagulant therapy in sepsis-induced ARDS, and our coagulopathy criteria may be clinically useful.
尽管急性呼吸窘迫综合征（ARDS）常伴有凝血功能障碍，但对其临床影响仍知之甚少。目的：本研究旨在阐明可用于预测预后的凝血功能障碍参数，并确定脓毒症相关性 ARDS 的抗凝治疗指征。方法：本研究纳入了来自两项全国性多中心前瞻性观察研究的脓毒症相关性 ARDS 患者。我们探讨了可预测 FORECAST 队列结局的凝血功能障碍参数，并在 SPICE-ICU 队列中验证了明确的凝血障碍标准。还评估了抗凝治疗的使用与结局之间的相关性。结果：在 FORECAST 研究中纳入了 181 例脓毒症相关性 ARDS 患者，在 SPICE-ICU 研究中纳入了 61 例患者。初步研究发现，凝血酶原时间国际标准化比值（INR）≥1.4 和血小板计数≤12×104/μL，以及血小板减少症和延长的凝血酶原时间（TEP）凝血障碍是最佳的凝血功能障碍参数，并进一步进行了分析；TEP 凝血障碍调整混杂因素后的院内死亡率比值比（OR）为 3.84（95%置信区间[CI]，1.66-8.87；P=0.005）。在验证队列中，院内死亡率的调整 OR 为 32.99（95%CI，2.60-418.72；P=0.002）。尽管无 TEP 凝血障碍的患者在第 1 至 4 天的氧合情况有显著改善，但 TEP 凝血障碍的患者则无明显改善（ΔPaO2/FiO2 比值，24±20 与 90±9；P=0.026）。此外，TEP 凝血障碍患者的抗凝治疗使用与死亡率和氧合恢复显著相关，但无 TEP 凝血障碍患者则无此相关性。结论：血小板减少症和延长的凝血酶原时间凝血障碍与脓毒症相关性 ARDS 的更好结局和对抗凝治疗的反应密切相关，我们的凝血障碍标准可能具有临床意义。
