Thromboelastometry Shows Early Hypercoagulation in Patients with Spontaneous Subarachnoid Hemorrhage.

BACKGROUND: The ability to achieve hemostasis after spontaneous subarachnoid hemorrhage (SAH) plays a pivotal role in outcome. Changes in coagulation in the early hours after SAH have been only sparsely investigated. OBJECTIVE: To investigate changes in coagulation after SAH and illuminate underlying mechanisms. METHODS: We enrolled 46 patients with spontaneous aneurysmal SAH. Blood samples were collected at admission and 24 hours after symptom onset. Thromboelastometry (ROTEM) was performed using the standard assays EXTEM, INTEM, and FIBTEM. Platelet maximum clot elasticity was calculated based on ROTEM results. Thrombin generation, levels of thrombin-antithrombin complex, fibrinogen, and coagulation factor XIII were measured. All data were compared with a gender-matched healthy control group. RESULTS: At admission (median, 3 hours 39 minutes from symptom onset), maximum clot firmness (EXTEM, P < 0.0001; INTEM, P = 0.08; FIBTEM, P < 0.0001) and platelet maximum clot elasticity (P < 0.0001) were higher in patients with SAH than in healthy controls. Thrombin generation showed higher, although nonsignificant, endogenous thrombin potential in patients with SAH than in healthy controls (P = 0.06), and thrombin-antithrombin complex levels were above the reference interval. Median fibrinogen and coagulation factor XIII levels were both within the reference parameters and remained increased 24 hours after symptom onset, whereas endogenous thrombin potential (P = 0.01) and thrombin-antithrombin complex levels decreased (P < 0.0001). CONCLUSIONS: Patients with SAH were in a hypercoagulable state at admission and remained so 24 hours after SAH. Increased clot firmness could be caused by increased platelet function, because platelet maximum clot elasticity was increased despite normal fibrinogen and coagulation factor XIII levels.

Coagulation Profile after Spontaneous Intracerebral Hemorrhage: A Cohort Study.

BACKGROUND: Intracerebral hemorrhage (ICH) causes death or disability and the incidence increases with age. Knowledge of acute hemostatic function in patients with ICH without anticoagulant and antiplatelet therapy is sparse. Increased knowledge of the coagulation profile in the acute phase of ICH could improve acute treatment and recovery. We investigated coagulation at admission and changes in coagulation during the first 24hours after symptom onset. METHODS: Enrolled were 41 ICH patients without anticoagulant or antiplatelet therapy admitted to Aarhus University Hospital, Denmark. Blood samples were collected at admission, 6, and 24hours after symptom onset. Thromboelastometry (ROTEM), thrombin generation, and thrombin-antithrombin (TAT) complex were analyzed. Clinical outcome was evaluated using the National Institute of Health Stroke Scale, the Modified Rankin Score, and mortality. RESULTS: At admission, compared with healthy individuals, ICH patients had increased maximum clot firmness (EXTEM P < .0001; INTEM P < .0001; FIBTEM P < .0001), increased platelet maximum clot elasticity (P < .0001) in ROTEM, higher peak thrombin (P < .0001) and endogenous thrombin potential (P = .01) in thrombin generation, and elevated TAT complex levels. During 24hours after significantly, while thrombin generation showed decreased peak thrombin (P < .0001) and endogenous thrombin potential (P < .0001). Coagulation test results did not differ between patients when stratified according to clinical outcome. CONCLUSIONS: ICH patients without anticoagulant or antiplatelet therapy demonstrated activated coagulation at admission and within 24hours after symptom onset.

Symptoms of Posttraumatic Stress after Intensive Care Delirium.

INTRODUCTION: Long-term psychological consequences of critical illness are receiving more attention in recent years. The aim of our study was to assess the correlation of ICU-delirium and symptoms of posttraumatic stress disorder (PTSD) anxiety and depression after ICU-discharge in a Danish cohort. METHODS: A prospective observational cohort study assessing the incidence of delirium in the ICU. Psychometrics were screened by validated tools in structured telephone interviews after 2 months (n = 297) and 6 months (n = 248) after ICU-discharge. RESULTS: Delirium was detected in 54% of patients in the ICU and symptoms of PTSD in 8% (2 months) and 6% (6 months) after ICU-discharge. Recall of ICU stay was present in 93%. Associations between ICU-delirium and post-discharge PTSD-symptoms were weak and insignificant. Memories of delusions were significantly associated with anxiety after two months. Remaining associations between types of ICU-memories and prevalence of post-discharge symptoms of PTSD, anxiety, and depression were insignificant after adjusting for age. Incidence of ICU-delirium was unaffected by preadmission use of psychotropic drugs. Prevalence of PTSD-symptoms was unaffected by use of antipsychotics and sedation in the ICU. CONCLUSION: ICU-delirium did not increase the risk of PTSD-symptoms at 2 and 6 months after ICU discharge.

[There is a need for further studies exploring the sleep in patients during intensive care unit admission]. / Behov for mere viden om søvn hos intensivpatienter.

We have been reviewing the literature on sleep in intensive care unit (ICU) patients, concluding that lack of normal sleep is a common problem. Polysomnography studies have demonstrated sleep deprivation and fragmentation. Delirium commonly coincides with sleep deprivation and shares the same symptoms. Mechanically ventilated patients have traditionally been sedated, making sleep scoring unreliable. There is a need for further studies exploring the relationship between circadian rhythm disturbance, sleep disorders, delirium and sedation in ICU patients.

[Recommendations for supplementary intravenous glucocorticosteroids in patients on long-term steroid therapy--a systematic review]. / Anbefalinger for supplerende glukokortikoid til operationspatienter i peroral steroidbehandling.

Patients on long-term steroid therapy are often given supplementary intravenous glucocorticosteroids during perioperative care. The reason is to minimize the risk of acute adrenal insufficiency, which is a potential life threatening condition. Based on a recent Cochrane review and the available literature on the subject a rational way in dealing with the matter is described.

[Evidence-based pharmacological interventions in intensive therapy]. / Evidensbaserede farmakologiske interventioner inden for intensiv terapi.

Very few randomised controlled trials (RCTs) conducted in intensive care units and using mortality as their primary outcome have shown a beneficial effect of pharmacological intervention on survival. Other types of evidence than the RCT should therefore be considered. Observational studies (clinical epidemiological studies) based on public registers and clinical databases have shown good agreement with the results from RCTs. The populations of Denmark and the remaining Scandinavian countries are well-registered and as such an ideal base for clinical, epidemiological studies supplementing the RCTs.

Infusion of hypertonic saline (7.5%) does not change neutrophil oxidative burst or expression of endothelial adhesion molecules after abdominal hysterectomy.

BACKGROUND: Previous studies found hypertonicity to affect neutrophils in intact laboratory animals and in human blood cell cultures. We investigated whether infusion of hypertonic saline in a clinical relevant dose before hysterectomy affected peripheral blood neutrophils and their response to surgery. METHODS: Fifteen women scheduled for open abdominal hysterectomy were randomized double-blindly to infusion of 4 mL/kg 7.5% NaCl, 4 mL/kg 0.9% NaCl, or 32 mL/kg 0.9% NaCl over 20 minutes. Blood was collected at baseline, after infusion, 1, 4, and 24 hours postoperatively for the determination of leukocyte and differential count, neutrophil membrane expression of endothelial adhesion molecules by flow cytometry, and O2- -generation by superoxide dismutase-inhibitable reduction of cytochrome C. RESULTS: Surgery induced well-known changes in the number and distribution of white blood cells, reduced the expression of adhesion molecules, and halved the superoxide production unrelated to the tonicity or volume of the infused fluids. CONCLUSION: Infusion of a clinically relevant dose of hypertonic saline has no detectable effect on the membrane expression of endothelial adhesion molecules or O2- -generation in circulating neutrophils after elective abdominal hysterectomy.