비외상성 중증 출혈 질환에서 급성 혈액응고장애의 발생

이선범,이성우,홍윤식,최성혁,문성우,김수진,윤영훈 대한응급의학회 2011 대한응급의학회지 Vol.22 No.1

Purpose: To find the incidence of acute coagulopathy following non-traumatic bleeding and to evaluate the factors related to the development of coagulopathy. Methods: Non-traumatic bleeding patients that visited the emergency department of a university teaching hospital from March 2007 to March 2010 were enrolled retrospectively. Patients >18-years-of-age with altered mental status and unstable vital signs, who required resuscitations, transfusion and emergency surgery were included. Patients with liver cirrhosis, chronic renal failure and warfarin medication were excluded. The presence of coagulopathy was defined as prothrombin time (PT) > 18 sec or PT (%) < 50% or activated partial thromboplastin time (APTT) > 60 sec. We analyzed the relationship between coagulopathy and age, presence of circulatory shock (systolic blood pressure < 90mmHg), hypothermia (body temperature (BT) < 36 C),acidity of arterial blood (arterial pH < 7.35), tissue hypoperfusion (base deficit ≤ -6 mmol/L), thrombocytopenia (<100000/uL) and sequential organ failure assessment (SOFA) score. Multiple logistic regression analysis was used to find factors that predicted the development of acute coagulopathy. Results: Non-traumatic bleeding patients (n=149) were analyzed. Sixteen patients (10.7%) showed acute coagulopathy. Ten patients (6.7%) expired during hospitalization. There were no significant differences in mortality, age, sex and full term for glasgow coma scale (GCS) according to presence of early coagulopathy. The presence of shock,metabolic acidosis, thrombocytopenia and high SOFA score were risk factors for the development of acute coagulopathy following non-traumatic bleeding. The group that had early coagulopathy received more much fluid and transfusions compared to the group that did not have coagulopathy (p<0.05). Conclusion: Acute coagulopathy causes organ dysfunction due to tissue hypoperfusion. Presently, patients who had acute coagulopathy following non-traumatic bleeding required large amounts of fluid and transfusion during acute resuscitation comparison with non-coagulopathy patients. Further study is needed to find whether the correction of coagulopathy improves the outcome of non-traumatic bleeding patients.

Coagulopathy in patients who experience snakebite

( Jae Seok Kim ),( Jae Won Yang ),( Min Soo Kim ),( Seung Tae Han ),( Bi Ro Kim ),( Myung Sang Shin ),( Jong In Lee ),( Byoung Geun Han ),( Seung Ok Choi ) 대한내과학회 2008 The Korean Journal of Internal Medicine Vol.23 No.2

Background/Aims: Coagulopathy is a common complication of snakebite, but there is little information on the clinical importance of coagulopathy. We analyzed the characteristics of coagulopathy after envenomation. Methods: Ninety-eight patients who experienced snakebite were enrolled in this study. We divided all the patients into three groups by the ISTH DIC scoring system: the normal, simple coagulopathy and DIC groups. The coagulopathy group included both the simple coagulopathy and DIC groups. We then conducted a case-control study. Results: There was a significant decrease in the Hct, protein, albumin, ALP and cholesterol levels in the coagulopathy group, and only the cholesterol level was deceased in the DIC group (p<0.05). Leukocytosis and rhabdomyolysis were significantly associated with coagulopathy, and hemolysis and rhabdomyolysis were associated with DIC (p<0.05). The presence of rhabdomyolysis was considered a risk factor for coagulopathy (p<0.05). These conditions continued for up to six to seven days after the snakebite. Conclusions: Evaluation of coagulopathy with using these characteristics is helpful to properly manage the patients who experience snakebite.

소모성 응고 장애가 병발된 대동맥류의 중재시술 및 연속된 수술로 성공적으로 치료한 증례

김지현 ( Jee Hyun Kim ),양범희 ( Bum-hee Yang ),이주희 ( Ju-hee Lee ),이상엽 ( Sang Yeub Lee ),배장환 ( Jang-whan Bae ),황경국 ( Kyung-kuk Hwang ),김상민 ( Sang Min Kim ) 대한내과학회 2016 대한내과학회지 Vol.90 No.6

Aortic aneurysm-induced chronic consumptive coagulopathy is a very rare complication but can be a source of critical complications and mortality. A 72-year-old man presented with a rapidly expanding descending thoracic aortic aneurysm with a penetrating ulcer and an infrarenal abdominal aortic aneurysm complicated by chronic coagulopathy. We were aware of the bleeding risk during surgical replacement based on the patient’s chronic coagulopathy status and successfully performed endovascular repair of the thoracic aortic aneurysm with a penetrating ulcer. Platelet transfusion, antiplatelet agents, and proteinase inhibitors improved the coagulopathy. A delayed type Ib endoleak developed, and the coagulopathy recurred 2 months later when the patient presented with purpura of both lower legs. We successfully managed the condition by elective surgical replacement of the entire aorta after improving the coagulopathy with platelet replacement and administration of proteinase inhibitors. (Korean J Med 2016;90:537-541)

A Case of Superwarfarin Intoxication without a Definitive History of Brodifacoum Exposure

이주희,김현,한혜숙,이기형,김승택 대한혈액학회 2009 Blood Research Vol.44 No.1

Superwarfarin intoxications that induce profound and prolonged coagulopathy are being increasingly reported, to such an extent that it is becoming a comparatively common intoxication. However, there have been few reported cases of superwarfarin intoxication with an inadvertent cause or an unknown origin. A 58-year-old man with recurrent painless hematuria was found to have an acquired deficiency of vitamin K dependent clotting factors, and a large amount of vitamin K was required to correct the coagulopathy. He had no history of warfarin use or any exposure to rodenticides, but brodifacoum was detected in his serum. It is important for physicians to be aware that significant coagulopathy can occur secondary to superwarfarin intoxication, without any known exposure to substances that might induce this.

중증 외상환자의 급성 외상응고장애 조기 예측인자 분석

이동언 ( Dong Eun Lee ),서강석 ( Kang Suk Seo ),이미진 ( Mi Jin Lee ),신수정 ( Su Jeong Shin ),류현욱 ( Hyun Wook Ryoo ),김종근 ( Jong Kun Kim ),박정배 ( Jung Bae Park ) 대한외상학회 2012 大韓外傷學會誌 Vol.25 No.3

Purpose: Clinical observation and research findings show that acute traumatic coagulopathy (ATC) is a major factor that must be addressed in the early care of severe trauma patients. ATC is associated with increased transfusion requirements and poor clinical outcomes. This study aimed to correlate the early predictable factors of ATC with the outcomes in severe trauma patients. Methods: Retrospective data from the trauma registry on severe trauma patients (Injury Severity Score (ISS) ≥16) were used to identify variables independently associated with coagulopathy. Univariate associations were calculated, and a multivariable logistic regression analysis was used to determine variables independently associated with ATC. Results: Patients were mostly male, aged 51.9±17.8 years, with an injury severity score of 24.1±12.4. ATC, as diagnosed in the emergency department (ED), occurred in 17% of the severe trauma patients. Using a multivariable logistic regression analysis, early predictable variables independently associated with ATC were base deficit (odds ratio (OR): 13.03; 95% confidence interval (CI): 3.47-48.93), acute liver injury (OR: 4.24; 95% CI: 1.06-17.00), and transfer from another hospital (OR: 21.00; 95% CI: 3.23-136.60). Conclusion: ATC is associated with mortality in severe trauma patients, and some variables associated with trauma and shock are an independent predictors of ATC. These variables contribute to the early recognition and management of coagulopathy, which may improve the outcome from trauma resuscitation. (J Korean Soc Traumatol 2012;25:72-78)

한국 독사교상의 혈액응고장애 특성 및 항사독소 사용의 효율성

이병준(Byoung Joon Lee),홍성일(Sung Il Hong),김해성(Hae Sung Kim),김태화(Tae Hwa Kim),이정훈(Jeong Hoon Lee),김한준(Han Joon Kim),류병윤(Byoung Yoon Ryu),김홍기(Hong Ki Kim) 대한외과학회 2007 Annals of Surgical Treatment and Research(ASRT) Vol.72 No.1

Purpose: Snake venom induced coagulopathy is a major cause of both morbidity and mortality among affected patients. The effects of venomous factors to coagulation cascade and fibrinolysis were verified by analyzing the hematological data and clinical features of envenomed patients, and the efficacy of blood products transfusion and antivenin against a Korean snakebite clarified. Methods: A retrospective study was conducted on 57 patients, admitted to the Department of Surgery of Chuncheon Sacred Hospital, between July 2002 and October 2005. According to the guidelines for assessing the severity of North American envenomination, the patients were divided into three groups according to severity, and the clinical course, DIC profile and usages of blood products and antivenin then analyzed. Results: Of the 15 patients in the severe group (26.3%), 9 (60.0%) developed severe coagulation abnormalities, similar to DIC. No substantial bleeding or thrombic event manifested. All the patients with initial hypofibrinogenemia (33.3%) and unmeasured PT/aPTT during the 2nd to 4th hospital days (46.7%) progressed to severe coagulopathy. On average, these patients received transfusions of 18.4±6.1 pints of FFP and 14.4±14.9 pints of platelet product. The average amounts of antivenin applied were 1.2±0.4, 1.7±0.5 and 2.8±0.8 vials for the Minimal, Moderate and Severe groups, respectively. There was no death due to a Korean snakebite during this period. Conclusion: Korean snake venom is assumed to be a complex mixture of anticoagulant, platelet active and fibrinolytic venom. The discrepancy between abnormal coagulopathy and the clinical course explains venom induced DIC-like syndrome. Hypofibrinogenemia is the most reasonable predictor of DIC-like syndrome. Abrupt prolongation of PT/aPTT during the 2nd to 4th hospital days must weigh against thrombocytopenia. An early antivenin injection, along with the proper use of blood products, could improve the clinical course of envenomed patients.

Cancer-Related Stroke: An Emerging Subtype of Ischemic Stroke with Unique Pathomechanisms

Oh Young Bang,Jong-Won Chung,Mi Ji Lee,Woo-Keun Seo,Gyeong-Moon Kim,Myung-Ju Ahn,OASIS-Cancer Study Investigators 대한뇌졸중학회 2020 Journal of stroke Vol.22 No.1

Systemic cancer and ischemic stroke are common conditions and two of the most frequent causes of death among the elderly. The association between cancer and stroke has been reported worldwide. Stroke causes severe disability for cancer patients, while cancer increases the risk of stroke. Moreover, cancer-related stroke is expected to increase due to advances in cancer treatment and an aging population worldwide. Because cancer and stroke share risk factors (such as smoking and obesity) and treatment of cancer can increase the risk of stroke (e.g., accelerated atherosclerosis after radiation therapy), cancer may accelerate conventional stroke mechanisms (i.e., atherosclerosis, small vessel disease, and cardiac thrombus). In addition, active cancer and chemotherapy may enhance thrombin generation causing stroke related to coagulopathy. Patients with stroke due to cancer-related coagulopathy showed the characteristics findings of etiologic work ups, D-dimer levels, and infarct patterns. In this review, we summarized the frequency of cancer-related stroke among patients with ischemic stroke, mechanisms of stroke with in cancer patients, and evaluation and treatment of cancer-related stroke. We discussed the possibility of cancer-related stroke as a stroke subtype, and presented the most recent discoveries in the pathomechanisms and treatment of stroke due to cancerrelated coagulopathy.

CASE REPORT : Drug reaction with eosinophilia and systemic symptom 증후군 환자에서 타이제사이클린 사용 후 급격히 발생한 혈액 응고 장애 1예

정영진 ( Yeong Jin Jeong ),강병주 ( Byeong Zu Ghanh ),이지완 ( Ji Wan Lee ),박진오 ( Jin Oh Park ),김태범 ( Tae Bum Kim ),조유숙 ( You Sook Cho ),문희범 ( Hee Bom Moon ),권혁수 ( Hyouk Soo Kwon ) 대한천식알레르기학회 2016 Allergy Asthma & Respiratory Disease Vol.4 No.1

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome-also known as drug-induced hypersensitivity syndrome-is an uncommon disease entity that manifests as fever, skin rash, blood cell abnormalities, lymphadenopathy, and often coagulopathy. Tigecycline is an antibiotic that is selectively used to treat complicated intra-abdominal and soft-tissue infections. Recently, a few cases of tigecycline-induced coagulopathy have been reported. Herein, we report a case of tigecycline-induced coagulopathy in a patient with DRESS syndrome. Both prothrombin time and activated partial thromboplastin time were abruptly exceeded beyond 180 seconds on day 6 of tigecycline treatment and normalized after discontinuation of tigecycline. (Allergy Asthma Respir Dis 2016;4:74-78)

Risk factor, monitoring, and treatment for snakebite induced coagulopathy: a multicenter retrospective study

Yong Jun Jeon,Jong Wan Kim,Sung Gil Park,신동우 대한중환자의학회 2019 Acute and Critical Care Vol.34 No.4

Background: Snakebite can cause various complications, including coagulopathy. The clinical features of snakebite-associated coagulopathy differ from those of disseminated intravascular coagulation (DIC) caused by other diseases and its treatment is controversial. Methods: We retrospectively reviewed the medical records of patients hospitalized for snakebite between January 2006 and September 2018. Results: A total of 226 patients were hospitalized due to snakebite. Their median hospital stay was 4.0 days (interquartile range, 2.0 to 7.0 days). Five patients arrived at hospital with shock and one patient died. Twenty-one patients had overt DIC according to the International Society of Thrombosis and Hemostasis scoring system. Two patients developed major bleeding complications. Initial lower cholesterol level at presentation was associated with the development of overt DIC. International normalization ratio (INR) exceeding the laboratory’s measurement limit was recorded as late as 4 to 5 days after the bite. Higher antivenom doses (≥18,000 units) and transfusion of fresh frozen plasma (FFP) or cryoprecipitate did not affect prolonged INR duration or hospital stay in the overt DIC patients without bleeding. Conclusions: Initial lower cholesterol level may be a risk factor for overt DIC following snakebite. Although patients lack apparent symptoms, the risk of coagulopathy should be assessed for at least 4 to 5 days following snakebite. Higher antivenom doses and transfusion of FFP or cryoprecipitate may be unbeneficial for coagulopathic patients without bleeding.

Successful Hemostasis by the use of Recombinant Factor VIIa in Uncontrolled Active Hemorrhage of Multiple Trauma Patients

( Yong Min Joo ),( Seok Ran Yeom ),( Ji Ho Ryu ),( Jin Woo Jeong ),( Yong In Kim ),( Mun Ki Min ),( Sung Wook Park ),( Suck Ju Cho ) 대한응급의학회 2011 대한응급의학회지 Vol.22 No.1

Purpose: Uncontrolled bleeding is a leading cause of death in multiple-injury patients. It is very difficult to control hemorrhage due to microvascular injury in soft tissue by surgery or vascular intervention. Thus, hemostatic agents such as recombinant activated coagulation factor VII (rFVIIa) have become popular with regard to reducing transfusion volumes and correcting the hemorrhage-associated coagulopathy. Methods: From March 2007 to January 2010 we used rFVIIa in 15 multiple-injury patients. Transfused packed red blood cell (pRBC) volume was compared before and 6 h after administration of rFVIIa. Complete blood count, prothrombin time and activated partial thromboplastin time were also checked. Results: Mortality rate correlated strongly with initial severity of coagulopathy. Transfused pRBC volumes per hour were reduced significantly after rFVIIa (p=0.01), and coagulopathy was also significantly corrected. Thromboembolic events such as acute myocardial infarction and cerebrovascular attack, a fatal complication of rFVIIa, did not occur. Conclusion: The administration of rFVIIa can correct hemorrhage associated coagulopathy and reduce pRBCs transfusion volume. A quick decision regarding the administration of rFVIIa is needed for a more favorable outcome in multiple-injury patients with hemorrhagic shock.