title: Disseminated intravascular coagulation at an early phase of trauma is associated with consumption coagulopathy and excessive fibrinolysis both by plasmin and neutrophil elastase.
abstract: BACKGROUND
  The aims of the present study were to confirm the consumption coagulopathy of disseminated intravascular coagulation with the fibrinolytic phenotype at an early phase of trauma and to test the hypothesis that thrombin-activatable fibrinolysis inhibitor, neutrophil elastase, and plasmin contribute to the increased fibrinolysis of this type of disseminated intravascular coagulation. Furthermore, we hypothesized that disseminated intravascular coagulation at an early phase of trauma progresses dependently to disseminated intravascular coagulation with a thorombotic phenotype from 3 to 5 days after injury.
  
  
  METHODS
  Fifty-seven trauma patients, including 30 patients with disseminated intravascular coagulation and 27 patients without disseminated intravascular coagulation, were studied prospectively. Levels of thrombin-activatable fibrinolysis inhibitor, tissue-type plasminogen activator plasminogen activator inhibitor-1 complex, plasmin alpha2 plasmin inhibitor complex, D-dimer, neutrophil elastase, and fibrin degradation product by neutrophil elastase were measured on days 1, 3, and 5 after trauma. The prothrombin time, fibrinogen, fibrin/fibrinogen degradation product, antithrombin, and lactate also were measured.
  
  
  RESULTS
  Independent of the lactate levels, disseminated intravascular coagulation patients showed a prolonged prothrombin time, lesser fibrinogen and antithrombin levels, and increased levels of fibrin/fibrinogen degradation product on day 1. Disseminated intravascular coagulation diagnosed on day 1 continued to late-phase disseminated intravascular coagulation on days 3 and 5 after trauma. Increased levels of tissue-type plasminogen activator plasminogen activator inhibitor-1 complex, plasmin alpha2 plasmin inhibitor complex, D-dimer, neutrophil elastase, and fibrin degradation product by neutrophil elastase but not thrombin-activatable fibrinolysis inhibitor were observed in the disseminated intravascular coagulation patients. No correlation was observed between plasmin alpha2 plasmin inhibitor complex and fibrin degradation product by neutrophil elastase in disseminated intravascular coagulation patients. Multiple regression analysis showed the disseminated intravascular coagulation score and the tissue-type plasminogen activator plasminogen activator inhibitor-1 complex levels on day 1 to correlate with the total volume of transfused blood. Patient prognosis deteriorated in accordance with the increasing disseminated intravascular coagulation severity.
  
  
  CONCLUSIONS
  Disseminated intravascular coagulation at an early phase of trauma is associated with consumption coagulopathy and excessive fibrinolysis both by plasmin and neutrophil elastase independent of hypoperfusion and continues to disseminated intravascular coagulation at a late phase of trauma. Increased fibrinolysis requires more blood transfusions, contributing to a poor patient outcome.
authors.affiliation: Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
authors.forename: Mineji
authors.initials: M
authors.lastname: Hayakawa
authors.forename: Atsushi
authors.initials: A
authors.lastname: Sawamura
authors.forename: Satoshi
authors.initials: S
authors.lastname: Gando
authors.forename: Nobuhiko
authors.initials: N
authors.lastname: Kubota
authors.forename: Shinji
authors.initials: S
authors.lastname: Uegaki
authors.forename: Hidekazu
authors.initials: H
authors.lastname: Shimojima
authors.forename: Masahiro
authors.initials: M
authors.lastname: Sugano
authors.forename: Masahiro
authors.initials: M
authors.lastname: Ieko
mesh_terms: D000328:Adult; D000368:Aged; D001803:Blood Transfusion; D004211:Disseminated Intravascular Coagulation / Q000097:blood* / Q000209:etiology; D005260:Female; D005341:Fibrinolysin / Q000502:physiology*; D005342:Fibrinolysis; D006801:Humans; D019272:Leukocyte Elastase / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D010976:Platelet Count; D011446:Prospective Studies; D014947:Wounds and Injuries / Q000097:blood* / Q000150:complications
chemical_list: D019272:Leukocyte Elastase; D005341:Fibrinolysin