중증패혈증 및 패혈증쇼크 환자에게서 파종성혈관내응고의 빈도 및 예후
Incidence and prognosis of disseminated intravascular coagulation in patients with severe sepsis or septic shock
4
조회
0
다운로드
3
인용
0
참고문헌
키워드
초록
목적:본 연구는 파종성혈관내응고(disseminated intravascular coagulation, DIC)에 대한 점수체계를 이용하여 중증패혈증 및 패혈증쇼크 환자에게서 파종성혈관내응고의 발생률과 예후를 확인하고자 하였다. 방법: 2008년 3월부터 2009년 2월까지 중증패혈증 및 패혈증쇼크으로 일개 3차 의료기관의 내과중환자실에 입원한 환자들을 대상으로 하였다. DIC 점수체계는 ISTH (International Society on Thrombosis and Haemostasis)를 이용하였으며, 연구기간 동안 각각 Day 0, Day 1, Day 2의 세 시점에서 계산하였다. 결과: 총 111명의 환자 중에서 제외기준에 해당하는 22명을 제외하고, 89명의 환자가 연구에 포함되었다. 환자의 평균 DIC score는 3.3±1.3였으며, 입원 초기 48시간 동안에 현성 DIC (overt DIC; DIC score≥5)의 발생 빈도는 33.8% (27/89)였다. Sequential Organ Failure Assessment (SOFA) score는 DIC score와 유의한 상관관계를 보여주었고, 현성 DIC 군에서 다른 환자군 보다 높은 점수를 보여주었다(p<0.05). 중환자실 사망과 병원 사망, 28일 사망률은 현성 DIC 군에서 각각 63.0%, 66.7%, 63.0%이었고, 이는 현성 DIC에 해당되지 않은 환자에 비해 통계적으로 유의하게 높았다. 다변량 분석에서는 Simplified Acute Physiology Score (SAPS) II가 병원 사망과 유의한 관련성을 보여주었고(p=0.002), 현성 DIC의 발생은 경계선상의 관련성을 보여주었다(p=0.043). 결론: DIC 진단을 위해 ISTH criteria를 사용한 경우, 중증패혈증 및 패혈증쇼크 환자에서 현성 DIC의 빈도는 33.8%이었고, 현성 DIC의 발생은 높은 장기부전 점수 및 병원 사망률과 관련이 있었다.
Abstract
Background/Aims: We investigated the incidence and prognosis of disseminated intravascular coagulation (DIC) using DIC scoring system in patients with severe sepsis or septic shock. Methods: Patients admitted to the intensive care unit (ICU) in a tertiary hospital for severe sepsis or septic shock were enrolled from Mar. 2008 to Feb. 2009. Using the International Society on Thrombosis and Haemostasis (ISTH) criteria, we calculated DIC score at three time points (Day 0, Day 1, and Day 2). Results: Among 111 patients with severe sepsis or septic shock, 89 (severe sepsis, 8; septic shock, 81) were enrolled. Mean DIC score at ICU admission was 3.3±1.3 and the incidence of overt DIC (DIC score ≥ 5) during the first 48 hours was 33.8% (27/89). Sequential Organ Failure Assessment (SOFA) score was well correlated with DIC score and was higher in patients with overt DIC than in those without. The ICU, hospital and 28-day death rates in patients with overt DIC were 63.0%, 66.7%, and 63.0%, respectively, which were significantly higher than in those without overt DIC. In multivariate analysis, Simplified Acute Physiology Score (SAPS) II was significantly associated with hospital death (p=0.002), and the occurrence of overt DIC showed a borderline significance (p=0.053). Conclusions: Using the ISTH criteria for DIC, the incidence of overt DIC was 33.8% in patients with severe sepsis or septic shock. The occurrence of overt DIC was associated with a higher organ failure score and hospital outcomes.
참고문헌 (22)
- Levi M, "Disseminated intravascular coagulation", N Engl J Med, 341, pp.586~592 (1999)
- Levi M, "Pathogenesis of disseminated intravascular coagulation in sepsis", JAMA, 270, pp.975~979 (1993)
- Levi M, "The cytokine- mediated imbalance between coagulant and anticoagulant mechanisms in sepsis and endotoxaemia", Eur J Clin Invest, 27, pp.3~9 (1997)
- Taylor FB, "Activated protein C in sepsis", J Thromb Haemost, 2, pp.708~717 (2004)
- Vervloet MG, "Derangements of coagulation and fibrinolysis in critically ill patients with sepsis and septic shock", Semin Thromb Hemost, 24, pp.33~44 (1998)
- "From the Centers for Disease Contro: increase in National Hospital Discharge Survey rates for septicemia-United States, 1979-1987", JAMA, 263, pp.937~938 (1990)
- Angus DC, "E5 murine monoclonal antiendotoxin antibody in gram-negative sepsis: a randomized controlled trial: E5 study investigators", JAMA, 283, pp.1723~1730 (2000)
- Bernard GR, "Efficacy and safety of recombinant human activated protein C for severe sepsis", N Engl J Med, 344, pp.699~709 (2001)
- Conkling PR, "Tumor necrosis factor induces tissue factor-like activity in human leukemia cell line U937 and peripheral blood monocytes", Blood, 72, pp.128~133 (1988)
- Esmon CT, "Inflammation and coagulation: linked processes potentially regulated through a common pathway mediated by protein C", Thromb Haemost, 66, pp.160~165 (1991)
- Bakhtiari K, "Prospective validation of the International Society of Thrombosis and Haemostasis scoring system for disseminated intravascular coagulation", Crit Care Med, 32, pp.2416~2421 (2004)
- Taylor FB Jr, "Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation", Thromb Haemost, 86, pp.1327~1330 (2001)
- Abraham E, "Efficacy and safety of monoclonal antibody to human tumor necrosis factor alpha in patients with sepsis syndrome. A randomized, controlled, double- blind, multicenter clinical trial. TNF-alpha MAb Sepsis Study Group", JAMA, 273, pp.934~941 (1995)
- Bone RC, "A second large controlled clinical study of E5, a monoclonal antibody to endotoxin: results of a prospective, multicenter, randomized, controlled trial. The E5 Sepsis Study Group", Crit Care Med, 23, pp.994~1006 (1995)
- Fisher CJ Jr, "Recombinant human interleukin 1 receptor antagonist in the treatment of patients with sepsis syndrome. Results from a randomized, double- blind, placebo-controlled trial. Phase III rhIL-1ra Sepsis Syndrome Study Group", JAMA, 271, pp.1836~1843 (1994)
- Rangel-Frausto MS, "The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study", JAMA, 273, pp.117~123 (1995)
- Dellinger RP, "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008", Crit Care Med, 36, pp.296~327 (2008)
- Gando S, "Disseminated intravascular coagulation is a frequent complication of systemic inflammatory response syndrome", Thromb Haemost, 75, pp.224~228 (1996)
- Wada H, "Comparison of diagnostic criteria for disseminated intravascular coagulation (DIC): diagnostic criteria of the International society of thrombosis and hemostasis and of the Japanese ministry of health and welfare for overt DIC", Am J Hematol, 74, pp.17~22 (2003)
- Angstwurm MW, "New disseminated intravascular coagulation score: a useful tool to predict mortality in comparison with Acute Physiology and Chronic Health Evaluation II and Logistic Organ Dysfunction scores", Crit Care Med, 34, pp.314~320 (2006)
- Abraham E, "Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death", N Engl J Med, 353, pp.1332~1341 (2005)
- Dhainaut JF, "Treatment effects of drotrecogin alfa (activated) in patients with severe sepsis with or without overt disseminated intravascular coagulation", J Thromb Haemost, 2, pp.1924~1933 (2004)