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Description of compensated and uncompensated disseminated

intravascular coagulation (DIC) responses (non-overt and overt DIC)
in baboon models of intravenous and intraperitoneal Escherichia coli
sepsis and in the human model of endotoxemia: Toward a better
definition of DIC
Fletcher B. Taylor, Jr, MD; Hideo Wada, MD; Gary Kinasewitz, MD

Objective: Work toward a better definition of disseminated In contrast, fibrin degradation products and the molecular
intravascular coagulation (DIC) by characterizing the difference markers thrombin/antithrombin, soluble fibrin monomer, protein
between compensated and uncompensated responses of the he- C, and activated protein C/inhibitor complexes responded consis-
mostatic system to inflammatory stress in baboons and human tently in a dose-dependent manner regardless of the length of
subjects using global coagulation and molecular marker assays of time after challenge. These variables exhibited this dose response
hemostatic, inflammatory, and endothelial perturbation. to 106 and 108 CFU/g of E. coli in absence of a fall in fibrinogen
Design: We conducted prospective evaluation of the response concentration. This was defined as a compensated hemostatic
of baboons to increasing concentrations of intravenous Esche- response to inflammatory stress (ie, non-overt DIC). The values of
richia coli, human subjects to intravenous endotoxin, and ba- these variables correlated closely with rising concentrations of
boons to intraperitoneal E. coli. markers of neutrophil activation (elastase/ⴤ 1 antitrypsin) and
Setting: Animal laboratory and medical intensive care facili- endothelial injury (soluble thrombomodulin). This was particularly
ties, University of Oklahoma Medical School laboratories. evident in the human response to endotoxin, in which there was
Subjects: Cynocephalus baboons; normal healthy male human abundant evidence of hemostatic marker response in absence of
subjects (age, 24 –37 yrs). a fall in platelet or fibrinogen concentration, both immediately
Measurements and Main Results: Global coagulation assays, after endotoxin infusion (first stage, 0 – 8 hrs after endotoxin) and
white blood cell counts, and molecular marker assays (ELISA) of later (second stage, 12– 48 hrs after endotoxin).
components of the inflammatory and hemostatic systems, neu- Conclusion: Global coagulation tests are most useful in detect-
trophil release products, and endothelial injury. A fall in both ing overt consumptive coagulopathy (overt DIC) near the time of
fibrinogen concentration and platelet counts indicated a decom- challenge or injury (1 to 6 hrs). Molecular markers can detect and
pensated hemostatic response to inflammatory stress (ie, overt grade the degree of hemostatic stress of a non-overt consumptive
DIC). These responses were observed 2– 6 hrs after intravenous coagulopathy (nonovert DIC). These markers correlate with de-
infusion of 109 and 1010 colony-forming units (CFU)/g of E. coli gree of endothelial cell injury and reveal a reperfusion injury stage
and after implantation of 1011 CFU/g of E. coli into the peritoneal (second stage) in the human endotoxin model of compensated
cavity. However, 6 hrs after E. coli challenge, these tests were hemostatic stress after all clinical symptoms have subsided and
much less reliable as markers of overt DIC because the fibrinogen the subjects have returned to work. (Crit Care Med 2000;
underwent an acute phase response and the platelet count fell 28[Suppl.]:S12–S19)
and remained depressed for 48 hrs in the face of a coagulopathic KEY WORDS: disseminated intravascular coagulation; sepsis;
response that was already beginning to resolve, as reflected by a septic shock; reticuloendothelial system; microvasculature; intra-
rising fibrinogen concentration. This lack of reliability was par- venous endotoxemia; systemic inflammation response syndrome;
ticularly evident in the E. coli peritonitis studies, in which one overt disseminated intravascular coagulation; non-overt dissem-
third of the animals recovered, one third remained sick for up to inated intravascular coagulation; microvascular reperfusion
14 days, and one third died.

From the Oklahoma Medical Research Founda- Supported, in part, by National Institutes of Health Address requests for reprints to: Fletcher B. Taylor,
tion (Dr. Taylor), and the University of Oklahoma Health 5 R01 GM37704 –12. Jr, Cardiovascular Biology Research Program, Okla-
Sciences Center (Dr. Kinasewitz), Oklahoma City, OK; and Presented, in part, at the Margaux Conference on homa Medical Research Foundation, 825 NE 13th
Mie University School of Medicine, Tsu-City, Japan (Dr. Critical Illness, Margaux, France, November 11–13, Street, Oklahoma City, OK 73104.
Wada). 1999. Copyright © 2000 by Lippincott Williams & Wilkins

S12 Crit Care Med 2000 Vol. 28, No. 9 (Suppl.)

variants of the response to E. burns. linked to the lethal chain of events. coli. A constant dynamic interac- tion at the blood/endothelial interface involving inflammatory and hemo- static mediator and regulatory net- works maintains both the flow and the Table 1. it should be pos- well as the development of the inflamma. and 1010 CFU/kg. coli com- ● Fourth.I deally. Malfunction of this transport organ in much as we use changes in the serum lowing points in mind: one of these ways can lead to hypoxic creatinine to diagnose renal dysfunc- stress and failure of other organs (ie. these circulating and fixed only marks dysfunction of the micro. tion. 9 (Suppl. static factors is common to all three prises (at least initially) an acute in- tors reflects stress on the microvascu. vascular col. von infused with four different concentrations of E. the reticuloendothelial/ microvasculature. etc. activation of hemostatic fac. including circulat- all the other organs because the hemo. The dys. sible to assess changes in the hemo- tory/hemostatic response. markers of perturbation of the reticu- ing blood components and the fixed static system is an integral part of this loendothelial system microvascular or- reticuloendothelial components that larger microvascular organ. in the capillary leak. Baboons were 1. fibrinogen degradation products) 2. which together exhibit mul- tiple functions ranging from endocrine and immune functions to transport. reversible microvascular thrombosis). This would include recognizing sponses: a) loss of fluid and shock (cap. coli: 106 colony-forming units (CFU)/kg (n ⫽ 2). static factors and use these to diagnose In studying the baboon model of Esch. Mediator—thrombin as measured by thrombin-antithrombin complex 3. platelet. platelets (center). trauma. b) loss of blood (hemorrhage). and sponse. Therefore. Oxidative metabolism (luminescence) Endothelial (microvascular) injury Figure 1. to sepsis. and assess patients’ in. lapse). dysfunction of the microvascular organ erichia coli sepsis. we have kept the fol. and fibrinogen (right) followed over a 48-hr period. ants. the systemic inflammatory/ multiple organ failure).) S13 . an acute inflammatory distur.. port organ. ● Finally. The transport function requires not only that the blood flow freely but also that the fixed vascular structures do not leak. Plasma tissue factor antigen degradation products (FDP) (left). Global coagulation tests (dose response to intravenous Escherichia coli). No. as bance as caused by E. Inhibitor—antithrombin (AT) 6. one flammation of the microvascular lar (transport) organ that is supplying is tempted to view them not only as circulatory system. thrombotic coagulopathic responses of the changes characteristic of recovery as illary leak syndrome. 108 Willebrand Factor 2. one would like to predict. Regulator—activated protein C as measured by activated protein C/protein C inhibitor complexes 4. because activation of hemo- hemostatic response to E. consumptive. Global coagulation tests (fibrinogen. c) obstruction of flow (reversible or ir. ● First. Elastase/⬀ 1AT complex 2. gan but also as one of the links in the are in contact with the blood. Although not always directly flammatory/hemostatic response ● Third. Kupffer cells) that are in contact with the blood. Substrate—protein C Neutrophil activation 1. function. one or more of the following three re. Tissue plasminogen activator. integrity of the microvascular trans. Crit Care Med 2000 Vol. this organ. Products—dimerized plasmin fragment D. This extensive organ can be viewed as consisting of blood and the fixed microvascular elements (endothelium. function of the hemostatic system not lethal chain of events in all three vari- ● Second. 109 CFU/kg (n ⫽ 3). soluble fibrin monomer 5. Diagnostic tests Hemostatic system activation and product formation 1. Soluble thrombomodulin CFU/kg (n ⫽ 2). This figure shows the responses of fibrin 3. vasculature but contributes to that dys- identify. fixed macrophages. It would be reasonable to assume components taken together constitute an organ. coli can result in activation of hemostatic factors occurs well as follow the full course of the re. 28.

ⴛ). particularly in trauma patients circles). 28. Each test has limits. only after the infusion of 109 and 1010 fused. coli in. In fact. nostic sign (5). No. advantages. Baboons were infused with four different concentrations of E. Therefore. Global tests of coagulation factors including fibrin degradation products (FDP). Infusion of lower concentrations of tion of a consumptive coagulopathy and target cells (tissues) at the time of E. 9 (Suppl. This puts a premium on diagnosis and on a treatment that is customized to a par- ticular host response. Furthermore. however. the fi. much as we cus- tomize antibacterial treatment to a particular bacterial organism. however. coli. and activated protein C/protein (1. marker of microvascular injury. coli (3). and specific uses as follows. The right column shows the responses of soluble thrombo- has specific limitations. CFU/kg. they have been in widespread clin- ical use and are available worldwide. Fibrin degradation products gave the lenge or the stage of the disease. status of the host at the time of chal. experience with in- pear on the field in all three types of colony-forming units (CFU)/kg concen. 109 CFU/kg (n ⫽ 3). ⴛ). coli sepsis models is to examine their re- sponse patterns as one progresses from decompensated to uncompensated injury of the microvascular (endothelial) trans- port system. platelets (center). overt DIC if given time. The status of the hosts’ effector hrs. and a kines. and in the case of 109 platelet counts often become depressed in anism that can be blocked if treated CFU/kg concentration of E. platelets. concentrations of E. All observations were made over a 48-hr that the concentration of fibrinogen fell period. strumented baboons has shown that responses. early enough or at the right time with brinogen. depending on the remained depressed for ⱖ48 hrs regard. The tests used in these stud- ies fall into three categories: those that measure activation of hemostatic compo- nents and product formation. Global Coagulation Tests. and soluble fibrin monomer (sFM. circles). and pro- a single agent. those that measure neutrophil activation and re- lease. circles). S14 Crit Care Med 2000 Vol. physicians often consider sustained leak syndrome or within days of irre. cytopenia (4). The center column shows the response of protein C (PC. and fibrinogen are diagnostic for overt disseminated intravascular coagulation (DIC). they are helpful in products (left). The first step in reviewing our experience with diagnostic tests in the baboon E. and elastase/alpha 1AT (ELAS. coli produced either no change or a (overt DIC) because other factors besides the challenge determines which of the rise in fibrinogen. ture may account for sustained thrombo- inant. Comparative Dose-Response Studies of Global Coagulation and Molecular Marker Tests in the Baboon Model of Intravenous Escherichia coli Sepsis. and fibrinogen (right) followed over a 48-hr period. the absence of any infusion of E. coli and rise in platelet count as a positive prog- appear on the field. each test C inhibitor complex (APC/PCI. Clin- ical investigators have shown that if these Figure 2. they responded identi. nonspecificity. which are themselves adjusting and reprogramming on the fly. ⴛ). Individually. critical care the host dies within hours of capillary Figure 1 shows that they were more sen. This in turn determines whether Platelets present a different problem. this is not recovered and rose above baseline by 48 longed depression can give false indica- true. As a result. overt DIC. phase response can mask evidence of ciated with injury of the microvascula- sible effector mechanisms will be dom. and those that measure endothelial cell injury (Table 1). trations of E. This sensitivity. they run different plays against cellular de- fenses. that because all the same players ap.) . coli as low as 108 trauma as a useful although nonspecific Even although the same players (cyto. being an acute phase protein. this acute thrombin (eg. 108 CFU/kg tests are scored as a group in conjunction (n ⫽ 2). coli: 106 colony-forming units (CFU)/kg (n ⫽ 2). The left column the diagnosis and characterization of shows the responses of thrombin/antithrombin complex (TAT. less of the concentration of E. sitive than fibrinogen and responded to thrombocytopenia after acute injury or versible microvascular thrombosis. 1010 CFU/kg E. they share a common mech. coli. Figure 1 shows modulin (sTM. neutrophil protease) asso- three variants and which of several pos. This figure shows the responses of fibrin degradation with clinical criteria. 2). coli. Molecular markers (dose response to intravenous Escherichia coli). activated coagulation factors) do cally to all concentrations of E.

Note that these late events occurred protein C network remained functional. the elastase/alpha 1AT complexes (circles) appeared and peaked twice (not shown). after a bolus gen. This delayed response was increasing amounts of APC/protein C in. coli. coli chal- lenge.Fib) (solid circles). This is shown by soluble fibrin monomer (sFM). long after the cytokines had at 4 and 8 hrs before rapidly returning to baseline. and there was a dose- peaked twice at 2 hrs and 7 hrs after endotoxin infusion. the concentrations of thrombin. The concentrations of inflammatory mediators tumor tite. coli followed by a second greater hemostatic response secondary to reperfusion of the microvasculature. This response pattern reflects an initial hemo- static response secondary to the direct effects of E. necrosis factor (TNF) (solid circles) and interleukin-6 (IL-6) (ⴛ) peaked at 2 hrs and 4 hrs. Crit Care Med 2000 Vol. (open circles) peaked at 3 hrs and 4 hrs followed by a second peak of IL-10 at 7– 8 hrs and a sustained ciprocal manner to the production of elevation of cortisol to 8 hrs after endotoxin infusion. coli. We concluded that the two-stage sFM response pattern was unique to the infusion of 108 CFU/kg of E.most consistent dose response to E. Second from top. the Figure 3. coli and then merged completely after infusion of 1010 CFU/kg. No. Bottom. the concentration of factor VIIa (ⴛ) response generation of activated protein did not reach a nadir until 12 hrs after endotoxin infusion. Top. mirrored by a reciprocal rise in the concentration of soluble tissue factor (TF) (open circles) and hibitor (PCI) complexes. Qualitative correlation of phagocyte elastase production and lactate concentration with appearance of plasma tissue factor anti- markers of the inflammatory and hemostatic system responses to endotoxin. The stronger direct effects of the higher con- centrations of E. Although the soluble fibrin (S. remained elevated before slowly returning toward baseline at 48 hrs had recovered normal activity and appe. which also peaked at 12 hrs. although fibrinogen levels were at or above baseline levels. 28. after the subjects had become asymptomatic and had returned to work the following day. coli infu- sion. The conclusion that the second peak of sFM represented reperfusion was supported by the rising lactate levels. coli. This two-stage re- sponse of sFM and the rapid decline of TAT toward baseline began to merge after infusion of 109 CFU/kg E. but like the cytokines (not shown). after endotoxin infusion. and a fall in factor VIIa at 12–24 hrs infusion of endotoxin (4 ng/kg). This response was dose dependent. coli at 2 hrs and a much larger peak at 24 hrs. Figure 1 shows that fibrin degradation products appeared in a dose-dependent manner within 6 hrs after E. 9 (Suppl. coli. This figure also shows that after infusion of 108 and 109 CFU/kg of E. like that returned toward baseline and the animals of the soluble thrombomodulin. whereas the inflammatory regulators IL-10 (triangles) and cortisol protein C concentration changed in a re. Molecular Markers of Activation of Hemostatic Factors and Neutrophils and of Injury to the Endothelium. Protein C concentration fell hemostatic mediators inhibitor complexes thrombin/antithrombin (TAT) (solid circles) and plasmin/ antiplasmin complex (PAP) (ⴛ) peaked at 4 and 2 hrs respectively before returning toward baseline. the TAT values returned to baseline before the response to E. coli had run its full course. which exhibited a small but significant peak soon after the infusion of 10 8 CFU/kg of E. respectively. In contrast. Figure 2 (center tier) shows that the before rapidly returning to normal. long after the initial inflammatory and C (APC) as indicated by the formation of hemostatic mediator and regulator responses had returned toward baseline. Second from bottom. coli.) S15 . coli overrode any evi- dence of reperfusion and/or produced conditions in which reperfusion did not occur. Figure 2 (left tier) shows that thrombin activation as reflected by assays of thrombin/ antithrombin (TAT) complex responded to as little as 106 CFU/kg of E. after the infusion of as little as 106 whereas the concentration of the protein C hemostatic regulator inhibitor complex (open circles) CFU/kg of E. a second fibrin degradation product peak appeared at 24 hrs after the E. the lactate concentration (ⴛ).

Values returned toward baseline after 24 Comparison of the intensity of the neutrophil response (COR/P) to endotoxin with the degree of to 48 hrs. the platelet (center). sFM to 10 CFU/kg of E. coli sepsis show the limits of global coagulation tests and offer a rationale supporting the use of molecular marker tests. and body temperature av- eraged 38. like those of TAT and COR/P. and with the hepatic (SGPT). All baboons received 1011 markers also reveal a two-stage response? colony-forming units (CFU)/kg of E. This figure shows the fibrin degradation product (FDP) (left). and symptomatic (rigors) responses. Can molecular markers be used to detect dysfunction of the microvascular hemostatic network under stress before it becomes decompensated in the human model of endotoxemia? And will these Figure 4.9 ⫻ 103/mm3. Although these studies of the baboon intravenous model of E.8 to increasing concentrations of E. coli.8 ⫻ 103/mm3. metabolic. Figure 1 shows that the global coagulation tests (with the excep- tion of platelet count) were above or near baseline up to 48 hrs. The fact that the protein C concentration was not 1 2 4 3 driven to ⬍35% after 10 9 and 10 10 CFU/kg of E. 9 (Suppl. the Human Model of Compensated Intra. Table 2.) . at which time the fibrinogen aver- aged 35%.2 1. and symptomatic response SGPT (units/L) 17 20 47 25 ble thrombomodulin. coli raises the question of a Neutrophil activity rate-limiting step (receptor inactivation) COR/P 41 35 77 60 Elastase/⬀1AT (ng/mL) 157 247 272 389 caused by the inflammatory response. the re- sponse to the higher E. Three different responses were Global and Molecular Marker Tests in observed: complete recovery (Well). coli in Rigors (0–4) 0. S16 Crit Care Med 2000 Vol.2 0. FDP averaged 23 ␮g/dL. Molecular markers of dysfunction centration of E. and death within 48 hrs (Died). sustained illness over ⱖ14 days (Sick). Global coagulation tests (response to intraperitoneal Escherichia coli). The concentrations or scores responded with evidence of reperfusion as of each of the four subjects between 0 and 48 hrs after endotoxin infusion were added and then divided reflected by the second soluble fibrin by the number of measurements taken (10 –12). two questions re- main. white blood cell count averaged 7. metabolic (lactate). and the fibrinogen venous Endotoxemia.4 1. SGPT. coli concentra- tions was characterized by higher peak concentrations of elastase/⬀1AT and by sTM concentrations that continued to rise during the full observation period.1 1. AT. coli intraperitoneally as a fibrin clot. Figure 2 (right) shows that sThrombomodulin (ng/mL) 16 22 33 39 markers of neutrophil activation (elas. serum glutamic-pyruvic 8 transaminase.1°C. In contrast.4 a dose-dependent manner. Figure 3 (bottom (right) responses of animals in each of these three categories. basal oxidase activity/phagocyte. endothelial (thrombomodulin) and hemostatic system (soluble fibrin) perturbation.3 2. coli challenge. WBC. was unique.it was increasingly overridden as the con. No. antithrombin. also shows that by 6 hrs. coli rose from 108 to 1010 Subject CFU/kg as suggested by the sustained de- pression of protein C concentrations to Mild Responders Moderate Responders 48 hrs after the E. Hepatic. sTM) also respond Lactate (meq/L) 2.4 2. Soluble fibrin (␮g/mL) 13 20 64 96 tase/⬀1AT) and endothelial injury (solu. Figure 1. at which time the fibrinogen averaged 223%. however. coli. 28. white blood cell count. and bocy temperature averaged 39°C. Endothelial and hemostatic perturbation Finally. suggesting a recovery that cor. The response of these markers. By comparison. white blood cell count averaged 1. FDP averaged 80 ␮g/dL. monomer peak and rising lactate during the same interval. This is striking evidence that the above-described molecular mark- ers registered inflammatory/hemostatic ac- tivity not detected by the global coagulation tests. the global coagulation tests did ap- propriately reflect consumption of hemo- static factors after 109 and 1010 CFU/kg of E.

Crit Care Med 2000 Vol. this model does not show the consistent tion of fibrin degradation products. hemostatic.two panels) shows the response of hemo. and if Figure 5 shows the same molecular this occurred during the asymptomatic pe. peaking when systemic inflammation response syn. the lation to elastase. This figure shows the fibrin degradation product (FDP) (left). These riod when subjects were already back at a given animal might respond to intra. and metabolic/ liver dysfunction that corresponded with the severity of clinical symptoms (rigors. in the course of peritonitis. Although Figure 4 shows that with the excep- static factors described previously in re. The right column shows the responses of elastase/ sustained or recurrent illness over 14 alpha 1AT complex (ELAS) (ⴛ) and soluble thrombomodulin (sTM) (solid circles). 9 (Suppl. and the implantation of a fixed concentration of fibrinogen (right) responses of animals in each of these three categories. with the mostatic mediators began their return to- ward baseline (stage 2). plasmin. factor VIIa reached its nadir. animals again were observed over 14 work. Recently. there are any tests that could predict how markers shown in Figures 2 and 3. animals that were infected but remained soluble tissue factor also began to rise at agulation or molecular marker tests are well. vation. coli intraperitoneally as a fibrin clot. This figure (top center panel) and activated protein C all peaked during criminate between or predict which of shows that animals that were instru- the symptomatic (stage 1) response to these three responses to E. coli sepsis/ systemic inflammation response syn- drome. transport organ. but that they also may distinguish between degrees of stress short of frank decompensation or overt DIC as would be reflected by a fall in platelet or fibrinogen concentrations. At no time were there significant declines in platelet or fi- brinogen concentrations. coli sepsis and endotoxemia outlined above offer some perspective on the fidelity and potential of various molecular markers. fatigue). coli. No. which reflects the highly variable courses we most commonly see in clini- cal practice (3). or death within 3–10 days. they did not reach of any value in assessing the status of the degradation products but to a lesser ex- their peak concentrations until 12–24 hrs reticuloendothelial system/microvascular tent. 28. We believed that this model might same fall in platelet counts as did the Although soluble fibrin monomer and help us determine whether the global co. long after the inflammatory and he. The three responses circles). The center column shows the responses of activated protein C/protein C inhibitor complex include a full recovery in 2–3 days. All baboons received 1011 colony-forming units (CFU)/kg of E. The responses observed in this model emphasize the importance Figure 5. occur. a (APC/PCI) (ⴛ) and protein C (PC) (solid circles). coli organisms (1 ⫻ 1011 CFU/kg) into pattern of thrombin/antithrombin complex (TAT) (ⴛ) and soluble fibrin monomer (sFM) (solid the peritoneal cavity. peritoneal E. Global Coagulation and Molecular Marker Tests in the Baboon Model of Escherichia Coli Peritonitis. the platelet (center). pacity of potential diagnostic tests to dis. Molecular markers (response to intraperitoneal Eshcerichia coli). Fibrinogen. Although the two intravenous models of E. coli. Three different responses of the host in determining which of sev- were observed: complete recovery (Well).) S17 . The well animals exhibited. This finding also applied to fibrin 2– 4 hrs into this stage. and lethal responses favored by investigators global coagulation tests were of limited cytokine production (top two panels). we have developed a conscious baboon model of interperitoneal E. coli might mented but not infected exhibited the bolus infusion (4 ng/kg) of endotoxin. studying intervention strategies. neither model mimics what is most often seen in hospital practice. reactant and relatively insensitive marker bomodulin followed a similar pattern to imals that have a prolonged/recurrent of DIC. drome-like response to E. Table 2 shows that subjects who were classified into groups 1 or 2 based on the severity of their symptoms also exhibited elevated levels of markers of neutrophil. days. The left column shows the E. and death within 48 eral different outcomes can arise after hrs (Died). sustained illness over ⱖ14 days (Sick). groups over the 14-day period of obser- flect production of thrombin. This raises the possibility that these molecular markers not only reflect microvascular/endothelial/hemostatic stress. Surprisingly. it does value in discriminating between the three The enzyme inhibitor complexes that re. lactate production. endothelial. particularly in those an. days. is of value in this model only early that of soluble tissue factor. Soluble throm. offer the opportunity to evaluate the ca. being an acute phase after endotoxin challenge.

these molecular markers offer a view of the status of the Figure 6. No. respectively. that this combination of molecular mark- ers could be clinically useful. bottom. Instrumen. peritonitis from an animal that subse- elevated) had already fallen toward base. activity and endothelial injury in this sick response to an inflammatory stimulus of after the implementation of 1 ⫻ 1011 group that may have accounted for the patients at risk. The sick animals ex. Cytokine in RNA response to endotoxin of monocytes harvested before and 24 hrs after reticuloendothelial system/microvascular intraperitoneal Escherichia Coli. the coagulation tests. the re. ment of the in vitro response of mono- hibited the familiar two-stage response of tation of these animals did not perturb cytes to endotoxin harvested from ba- hemostatic factors (TAT and sFM). This suggests side. coli. IL-18) messenger RNA responses of a baboon that died and one that survived the organ over the full course of the disorder intraperitoneal instillation of 1011 colony-forming units (CFU)/kg E. P redictive tests most likely will come from assess- ment of host cell responses to in vitro lipopolysaccha- ride stimulation. coli.6 to 1. temperature. Figure 6 (top) sum- blood cell count. IL-15. and global coagulation than those of the surviving but sick ani. 9 (Suppl. cytes/mL harvested before induction of TAT levels (although remaining slightly tween these two groups. ited response of markers of hemostatic that there was sustained inflammatory As far as the question of predicting the and neutrophil/endothelial perturbation. The these molecular markers. how. continued production of sFM. These studies suggest responses of monocytes harvested 24 hrs after instillation of intraperitoneal E.2 ⫻ 106 mono- those of the well animals and because the elastase did not differ significantly be. as in the sick and nonsurvivor ized to beta actin (housekeeping gene). IL-12. The bars represent the fold increase or S18 Crit Care Med 2000 Vol. This pri- mate model of peritonitis. sFM was especially helpful in this model shows the TAT and sTM responses of the coli peritonitis suggest that this approach because by 72 hrs. because it mimics the vari- able responses seen in the clinical practice. the be obtained by clinical signs and global responses of monocytic harvested before (T-0) instillation of intraperitoneal E. particularly if they were available for use at the bed- exception of protein C. ever. Top.) . provides an opportunity to determine whether such an approach will aid in predicting the out- come in patients who are at risk. The sick animals also exhibited a reached a similar nadir of 45% to 50% in concentrations of mRNA were normal- strong elastase response and sustained the well. white nonsurvivors were significantly greater merits further study. which coincided groups. Figure 5 also boons before and early in the course of E. a relatively lim. coli in a fibrin clot. whereas the response of sFM and endotoxin of 0. results from the assess- CFU/kg of E. with the late sFM response. Taken as a group. The line. 28. marizes the cytokine mRNA responses to test responses differed very little from mals. elevation of sTM levels. coli. The activation of protein C. interleukin (IL)-10. The figure shows cytokine (tumor necrosis factor [TNF]. as reflected by activated protein C/protein C inhibitor (APC/PCI) complex formation appears to coincide with the severity of the clinical response (died ⬎ sick ⬎ well). The solid and in the sick group of animals that cannot open bars represent the responses of nonsurvivor and survivor animals. Finally. sponse of protein C (anticoagulant) quently died and from one that lived.

and cleavage of platelet GPV during endo- This primate model of peritonitis. be. Kinasewitz GT. Kameue T. they produce mediator and under an. and more in vitro lipopolysaccharide stimulation. 11:465– 480 6. al. 25:1820 –1826 differs from that of the survivor. The (6). Nakase T. gust 17. Gilbert JA Jr. 27:313–318 Crit Care Med 2000 Vol. 51:255–260. Wakita Y. 1999. Emerg Med Clin North detection (eg. et al: at 24 hrs after induction of peritonitis. No. Washington. 28. et al: Partic- flammatory cells such as monocytes and ipation of tissue factor and thrombin post- fore induction of peritonitis. collected over a 4 –5 day period just be. In both animals the circulating cyto. et al: one does not know how far this approach The extent of traumatic damage determines a will take us. siveness of peripheral blood mononuclear tween what we measure in plasma and 1. 2. 5 ng/mL TNF). when one considers the capacity of in.) S19 . this suggests that 13:100 –109 survivor’s response pattern was reversed predictive tests most likely will come 4. 9 (Suppl. toxin shock in the rat. plasma-soluble fibrin monomer levels in pa. Majetschak M. survivor relative to the nonsurvivor. Scalzi RP: Disseminated intra- an approach will aid in predicting the vascular coagulation. et al: Increased cells from patients with blunt injuries. Flach R. Am J Hematol 1996. Crit what is actually happening in tissues. Care Med 1999. This seems particularly true ulation. More such that under one set of conditions 3. Nanzaki S. Freund M. Ravanat C. Kreuzfelder E. outcome in patients who are at risk. Peer GT. Am 1993. kine response pattern of the nonsurvivor macrophages to reprogram “on the fly” Crit Care Med 1997. In our opinion. Because these are preliminary results. Wada H. Schwartz C. Shock 1999. Society on Thrombosis and Haemostasis. Abstract # 5130 pre- IL-10 and IL-15 were produced by the sented at: XVII Congress of the International cause it mimics the variable responses survivor as compared with the nonsurvi. Gando S. Peritonitis in the baboon: A primate model ulator cytokine) were produced by the other set produce regulatory cytokines that simulates human sepsis. The cyto- traumatic systemic inflammatory syndrome. provides an vor. However.decrease of mRNA over baseline and are though the plasma measurements are tients with disseminated intravascular coag- the average of four to five blood samples valuable. Au- seen in the clinical practice. DC opportunity to determine whether such kine levels at 24 hrs were below level of 5. et al: TNF (mediator cytokine) and IL-15 (reg. Chang ACK. at from assessment of host cell responses to Thrombin independent thrombocytopenia which time less TNF and IL-12. it seems obvious graded depression of the endotoxin respon- REFERENCES that there is a partial discrepancy be.