Lorente J A, García-Frade L J, Landín L, de Pablo R, Torrado C, Renes E, García-Avello A
Unidad de Cuidados Intensivos, Hospital Ramón y Cajal, Madrid, Spain.
Chest. 1993 May;103(5):1536-42. doi: 10.1378/chest.103.5.1536.
To investigate the time course and the relation to prognosis of coagulation and fibrinolytic abnormalities in patients with septic shock.
Forty-eight consecutive patients admitted to the medical ICU with the diagnosis of septic shock (diagnosed by defined criteria) were studied. Mortality was 25 of 48. Mean age was 57 +/- 7.3 years. Blood samples were obtained on days 1, 4, and 7 after hospital admission to measure tissue-type plasminogen activator antigen (t-PA), urokinase-type plasminogen activator (u-PA), plasminogen activator inhibitor antigen (PAI-1), plasminogen, alpha 2-antiplasmin, fibrinogen, antithrombin III, protein C, protein S, thrombin-antithrombin complexes (TAT), D-dimer, and von Willebrand factor-related antigen (vWF:Ag).
All patients showed marked abnormalities in both the coagulation and fibrinolytic systems. There were signs of coagulation activation and elevation of both activators and inhibitors of fibrinolysis. Nonsurvivors showed lower levels of protein C and antithrombin III and higher concentration of TAT than survivors. While both t-PA and PAI-1 concentrations were high in survivors and nonsurvivors, only survivors showed a progressive normalization of both parameters during the study period. Low plasminogen levels and plasminogen/alpha 2-antiplasmin ratio were found in both groups, presenting a trend toward normalization only in survivors. The differences reported were not apparent at the time of hospital admission.
Septic shock is characterized by coagulation activation and fibrinolysis activation and inhibition. Nonsurvivors present a particular hemostatic profile characterized by a more marked activation of coagulation and a more intense inhibition of fibrinolysis. None of the abnormalities studied was significantly different between survivors and nonsurvivors at the time of hospital admission. In the presence of fibrin formation, nonsurvivors present a maintained imbalance in the fibrinolytic response determined by higher PAI-1 plasma concentration, probably contributing to their poor outcome.
研究脓毒性休克患者凝血和纤溶异常的时间进程及其与预后的关系。
对48例连续入住内科重症监护病房且诊断为脓毒性休克（根据明确标准诊断）的患者进行研究。48例患者中25例死亡。平均年龄为57±7.3岁。在入院后第1天、第4天和第7天采集血样，检测组织型纤溶酶原激活物抗原（t-PA）、尿激酶型纤溶酶原激活物（u-PA）、纤溶酶原激活物抑制剂抗原（PAI-1）、纤溶酶原、α2-抗纤溶酶、纤维蛋白原、抗凝血酶III、蛋白C、蛋白S、凝血酶-抗凝血酶复合物（TAT）、D-二聚体和血管性血友病因子相关抗原（vWF:Ag）。
所有患者的凝血和纤溶系统均显示明显异常。存在凝血激活以及纤溶激活剂和抑制剂水平升高的迹象。非幸存者的蛋白C和抗凝血酶III水平低于幸存者，TAT浓度高于幸存者。虽然幸存者和非幸存者的t-PA和PAI-1浓度均较高，但只有幸存者在研究期间这两个参数逐渐恢复正常。两组均发现纤溶酶原水平和纤溶酶原/α2-抗纤溶酶比值较低，仅幸存者呈现出恢复正常的趋势。所报告的差异在入院时并不明显。
脓毒性休克的特征是凝血激活以及纤溶激活和抑制。非幸存者呈现出一种特殊的止血特征，其特点是凝血激活更为明显，纤溶抑制更为强烈。在入院时，幸存者和非幸存者之间所研究的异常情况均无显著差异。在存在纤维蛋白形成的情况下，非幸存者由于血浆PAI-1浓度较高，在纤溶反应中呈现持续的失衡，这可能导致其预后不良。
