Abstract
Coagulation abnormalities are commonly found in critically ill patients. A myriad of altered coagulation parameters are often detectable, such as thrombocytopenia, prolonged global coagulation times, reduced levels of coagulation inhibitors, or high levels of fibrin split products. Each of these derangements in clotting may derive from a variety of different pathophysiological mechanisms. Proper identification of the underlying causes for these coagulation abnormalities is required, since various coagulation disorders may necessitate different diagnostic and therapeutic management strategies. This chapter reviews the most frequently occurring coagulation abnormalities in critically ill patients with emphasis on the differential diagnosis, the underlying pathogenetic pathways, and the appropriate management strategy.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Levi M, van der Poll T. Hemostasis and coagulation. In: Norton JA, Bollinger RR, Chang AE, Lowry SF, editors. Surgery: scientific basis and current practice. New York: Springer-Verlag; 2001.
Schneeweiss S, Seeger JD, Landon J, Walker AM. Aprotinin during coronary-artery bypass grafting and risk of death. N Engl J Med. 2008;358:771–83.
Levi M, Opal SM. Coagulation abnormalities in critically ill patients. Crit Care. 2006;10:222.
Levi M, Schultz M, van der Poll T. Coagulation biomarkers in critically ill patients. Crit Care Clin. 2011;27:281–97.
Levi M. Adequate thromboprophylaxis in critically ill patients. Crit Care. 2010;14:142.
Chakraverty R, Davidson S, Peggs K, Stross P, Garrard C, Littlewood TJ. The incidence and cause of coagulopathies in an intensive care population. Br J Haematol. 1996;93:460–3.
MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55:39–44.
Stephan F, Hollande J, Richard O, Cheffi A, Maier-Redelsperger M, Flahault A. Thrombocytopenia in a surgical ICU. Chest. 1999;115:1363–70.
Hanes SD, Quarles DA, Boucher BA. Incidence and risk factors of thrombocytopenia in critically ill trauma patients. Ann Pharmacother. 1997;31:285–9.
Akca S, Haji-Michael P, de Medonca A, Suter PM, Levi M, Vincent JL. The time course of platelet counts in critically ill patients. Crit Care Med. 2002;30:753–6.
Vanderschueren S, De Weerdt A, Malbrain M, Vankersschaever D, Frans E, Wilmer A, et al. Thrombocytopenia and prognosis in intensive care. Crit Care Med. 2000;28:1871–6.
Baughman RP, Lower EE, Flessa HC, Tollerud DJ. Thrombocytopenia in the intensive care unit. Chest. 1993;104:1243–7.
Strauss R, Wehler M, Mehler K, Kreutzer D, Koebnick C, Hahn EG. Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med. 2002;30:1765–71.
Oppenheim-Eden A, Glantz L, Eidelman LA, Sprung CL. Spontaneous intracerebral hemorrhage in critically ill patients: incidence over six years and associated factors. Intensive Care Med. 1999;25:63–7.
Shorr AF, Thomas SJ, Alkins SA, Fitzpatrick TM, Ling GS. D-dimer correlates with proinflammatory cytokine levels and outcomes in critically ill patients. Chest. 2002;121:1262–8.
Owings JT, Gosselin RC, Anderson JT, Battistella FD, Bagley M, Larkin EC. Practical utility of the D-dimer assay for excluding thromboembolism in severely injured trauma patients. J Trauma. 2001;51:425–9.
Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699–709.
Gando S, Nanzaki S, Sasaki S, Kemmotsu O. Significant correlations between tissue factor and thrombin markers in trauma and septic patients with disseminated intravascular coagulation. Thromb Haemost. 1998;79:1111–5.
Greaves M, Preston FE. Approach to the bleeding patient. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, editors. Hemostasis and thrombosis. Basic principles and clinical practice. 4th ed. Philadelphia: Lippincott William & Wilkins; 2001. p. 1031–43.
Edmunds LH. Hemostatic problems in surgical patients. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, editors. Hemostasis and thrombosis. Basic principles and clinical practice. 4th ed. Philadelphia: Lippincott William & Wilkins; 2001. p. 1031–43.
Kitchen S, Preston FE. Standardization of prothrombin time for laboratory control of oral anticoagulant therapy. Semin Thromb Hemost. 1999;25:17–25.
Bailey B, Amre DK, Gaudreault P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation. Crit Care Med. 2003;31:299–305.
Mavrommatis AC, Theodoridis T, Orfanidou A, Roussos C, Christopoulou-Kokkinou V, Zakynthinos S. Coagulation system and platelets are fully activated in uncomplicated sepsis. Crit Care Med. 2000;28:451–7.
Folman CC, Linthorst GE, van Mourik J, van Willigen G, de Jonge E, Levi M, et al. Platelets release thrombopoietin (Tpo) upon activation: another regulatory loop in thrombocytopoiesis? Thromb Haemost. 2000;83:923–30.
Francois B, Trimoreau F, Vignon P, Fixe P, Praloran V, Gastinne H. Thrombocytopenia in the sepsis syndrome: role of hemophagocytosis and macrophage colony-stimulating factor. Am J Med. 1997;103:114–20.
Lowenberg EC, Meijers JC, Levi M. Platelet-vessel wall interaction in health and disease. Neth J Med. 2010;68:242–51.
Levi M, ten Cate H. Disseminated intravascular coagulation. N Engl J Med. 1999;341:586–92.
Warkentin TE, Aird WC, Rand JH. Platelet-endothelial interactions: sepsis, HIT, and antiphospholipid syndrome. Hematology. 2003;1:497–519.
Verma AK, Levine M, Shalansky SJ, Carter CJ, Kelton JG. Frequency of heparin-induced thrombocytopenia in critical care patients. Pharmacotherapy. 2003;23:745–53.
Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332:1330–5.
Warkentin TE. Heparin-induced thrombocytopenia: pathogenesis and management. Br J Haematol. 2003;121:535–55.
Thiele T, Selleng K, Selleng S, Greinacher A, Bakchoul T. Thrombocytopenia in the intensive care unit-diagnostic approach and management. Semin Hematol. 2013;50:239–50.
Moake JL. Thrombotic microangiopathies. N Engl J Med. 2002;347:589–600.
Tsai HM. Platelet activation and the formation of the platelet plug: deficiency of ADAMTS13 causes thrombotic thrombocytopenic purpura. Arterioscler Thromb Vasc Biol. 2003;23:388–96.
Makoni SN. Acute profound thrombocytopenia following angioplasty: the dilemma in the management and a review of the literature. Heart. 2001;86:e18.
Levi M, van der Poll T, Schultz M. New insights into pathways that determine the link between infection and thrombosis. Neth J Med. 2012;70:114–20.
Levi M, Meijers JC. DIC: which laboratory tests are most useful. Blood Rev. 2011;25:33–7.
Levi M. Current understanding of disseminated intravascular coagulation. Br J Haematol. 2004;124:567–76.
Taylor Jr FB, Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001;86:1327–30.
Wada H, Hatada T, Okamoto K, Uchiyama T, Kawasugi K, Mayumi T, et al. Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC. Am J Hematol. 2010;85:691–4.
Dhainaut JF, Yan SB, Joyce DE, Pettila V, Basson BR, Brandt JT, et al. Treatment effects of drotrecogin alfa (activated) in patients with severe sepsis with or without overt disseminated intravascular coagulation. J Thromb Haemost. 2004;2:1924–33.
Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin Nephrol. 1996;46:199–205.
Muntean W. Coagulation and anticoagulation in extracorporeal membrane oxygenation. Artif Organs. 1999;23:979–83.
Rodgers RP, Levin J. A critical reappraisal of the bleeding time. Semin Thromb Hemost. 1990;16:1–20.
Forestier F, Coiffic A, Mouton C, Ekouevi D, Chene G, Janvier G. Platelet function point-of-care tests in post-bypass cardiac surgery: are they relevant? Br J Anaesth. 2002;89:715–21.
Levi M. Cancer and DIC. Haemostasis. 2001;31 Suppl 1:47–8.
Teufelsbauer H, Proidl S, Havel M, Vukovich T. Early activation of hemostasis during cardiopulmonary bypass: evidence for thrombin mediated hyperfibrinolysis. Thromb Haemost. 1992;68:250–2.
Hirsh J, Heddle N, Kelton JG. Treatment of heparin-induced thrombocytopenia: a critical review. Arch Intern Med. 2004;164:361–9.
Hellstern P, Muntean W, Schramm W, Seifried E, Solheim B. Practical guidelines for the clinical use of plasma. Thromb Res. 2002;107 Suppl 1:S53–57.
Mannucci PM, Levi M. Prevention and treatment of major blood loss. N Engl J Med. 2007;356:2301–11.
Mannucci PM. Desmopressin (DDAVP) in the treatment of bleeding disorders: the first 20 years. Blood. 1997;90:2515–21.
Levi M, Cromheecke ME, de Jonge E, Prins MH, de Mol BJ, Briët E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet. 1999;354:1940–7.
Porte RJ, Molenaar IQ, Begliomini B, Groenland TH, Januszkiewicz A, Lindgren L, et al. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. EMSALT Study Group. Lancet. 2000;355:1303–9.
Roberts I, Shakur H, Ker K, Coats T. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2011;(1):CD004896.
Friederich PW, Henny CP, Messelink EJ, Geerdink MG, Keller T, Kurth KH, et al. Effect of recombinant activated factor VII on perioperative blood loss in patients undergoing retropubic prostatectomy: a double-blind placebo-controlled randomised trial. Lancet. 2003;361:201–5.
Hedner U, Erhardtsen E. Potential role for rFVIIa in transfusion medicine. Transfusion. 2002;42:114–24.
Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med. 2010;363:1791–800.
Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Br J Haematol. 2009;145:24–33.
Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. Drotrecogin alfa (Activated) in adults with septic shock. N Engl J Med. 2012;366:2055–64.
Levi M, Levy M, Williams MD, Douglas I, Artigas A, Antonelli M, et al. Prophylactic heparin in patients with severe sepsis treated with drotrecogin alfa (activated). Am J Respir Crit Care Med. 2007;176:483–90.
Levi M, van der Poll T. Thrombomodulin in sepsis. Minerva Anestesiol. 2013;79:294–8.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2016 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Levi, M., Opal, S.M. (2016). Coagulation Abnormalities in Critically Ill Patients. In: O'Donnell, J., Nácul, F. (eds) Surgical Intensive Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19668-8_34
Download citation
DOI: https://doi.org/10.1007/978-3-319-19668-8_34
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-19667-1
Online ISBN: 978-3-319-19668-8
eBook Packages: MedicineMedicine (R0)