Coagulation Score Research Articles

Comparison between clinical features and prognosis of malignancy- and non-malignancy\u2013associated pediatric hemophagocytic lymphohistiocytosis

BackgroundThe differences between the clinical characteristics and survival time in malignancy- and non-malignancy–associated secondary hemophagocytic lymphohistiocytosis (HLH) are unclear. Here, we describe the clinical characteristics, prognostic factors, and survival outcomes of malignancy-associated HLH compared to that of non-malignancy–associated HLH.MethodsWe retrospectively analyzed 91 pediatric patients with HLH (age < 14 years) at the Affiliated Hospital of Qingdao University Pediatric Department between January 2005 and October 2016. The patients were divided into the malignancy-associated group (n = 22) and non-malignancy–associated group (n = 69, also considered the control group). The clinical features were compared using the Mann–Whitney U and χ2 tests. The overall survival time was compared using log rank and Mann–Whitney U tests.ResultsHemoglobin (HGB; p = 0.004), alanine aminotransferase (ALT; p = 0.002), and aspartate aminotransferase (AST; p = 0.001) levels in the malignancy-associated group differed from that in the non-malignancy–associated group. The mean survival times were 26.9 ± 3.82 months (malignancy-associated HLH) and 35.03 ± 2.19 months (non-malignancy–associated HLH). The overall survival time between the two groups was not statistically significantly different (p = 0.055). Univariate analysis showed that disseminated intravascular coagulation (DIC) score > 5 (p = 0.001), albumin < 25 g/L (p = 0.000), HGB < 60 g/L (p = 0.001), and platelet count (PLT) < 30 × 109/L (p = 0.042) correlated with prognosis. Multivariate Cox analysis showed that albumin < 25 g/L (p = 0.017), HGB < 60 g/L (p = 0.027), and bone marrow hemophagocytosis (p = 0.034) correlated with worse prognosis.ConclusionsPatients with non-malignancy–associated HLH do not have better survival, although their prognosis is relatively better in clinical practice. A higher DIC score at diagnosis and lower albumin, HGB, and PLT levels are negative prognostic factors in malignancy-associated HLH.

Association of vitamin D deficiency with clinical outcomes in critically ill Korean children.

BACKGROUND/OBJECTIVESVitamin D is a pleiotropic hormone that affects various body organ systems. We evaluated the prevalence of a vitamin D deficiency (VDD) and its potential role in the clinical condition of critically ill Korean children.SUBJECTS/METHODSPatients under 18 years old with a 25(OH) vitamin D measurement on the first day of PICU admission were included from among the children admitted to the pediatric intensive care unit (PICU) of our tertiary children's hospital between October 2017 and January 2019.RESULTSA total of 172 pediatric patients were enrolled. The mean 25(OH) vitamin D level was 17.5 ± 12.8 ng/mL. There was a 65.1% prevalence of VDD (25(OH) vitamin D level < 20 ng/mL). VDD was associated with age at PICU admission, gastrointestinal/hepatobiliary disorders, International Society of Thrombosis and Hemostasis disseminated intravascular coagulation (ISTH DIC) score, pediatric multiple organ dysfunction syndrome (pMODS) score and with several laboratory test findings including hemoglobin, platelet, C-reactive protein, serum albumin, total bilirubin, prothrombin time, and anti-thrombin III levels. Most of these parameters also showed significant linear correlations with the 25(OH) vitamin D level (P < 0.05). However, no statistically meaningful association was found between VDD and other clinical conditions such as the need for a mechanical ventilator, requirement for vasoactive drugs, duration of the PICU and hospital stays, or PICU mortality.CONCLUSIONThere is a high prevalence of VDD in critically ill Korean children. There were significant associations between the 25(OH) vitamin D level and gastrointestinal/hepatobiliary disorders, the pMODS score and with coagulation related factors. Further large-scale studies with more specific subgroup analyses are required to more precisely assess the clinical implications of VDD in critically ill pediatric patients.

Significance of plasma fibrinogen level and antithrombin activity in sepsis: A multicenter cohort study using a cubic spline model

IntroductionSepsis leads to coagulopathy by the activation of inflammatory mediators and vascular endothelial cell injury. A number of biomarkers are used to evaluate coagulopathy on sepsis. Fibrinogen and antithrombin activity have been reported as biomarkers of coagulopathy; however, the utility of these two markers has not been well established. This study aimed to evaluate the detailed association between these two markers and clinical outcomes in sepsis patients. Materials and methodsThis was a post hoc analysis of a multicenter, prospective cohort study conducted in 59 intensive care units throughout Japan from January 2016 to March 2017. We included 1103 adult patients with severe sepsis based on the Sepsis-2 criteria. The associations between the coagulation markers and in-hospital mortality were examined using linear and non-linear logistic regression analyses. We also evaluated the associations between the coagulation markers and disseminated intravascular coagulation (DIC) scores. The International Society on Thrombosis and Haemostasis overt DIC score was calculated after subtracting the fibrinogen component. ResultsThe decreased levels of the fibrinogen and antithrombin activity were significantly associated with an increase in mortality (P = 0.011 and 0.002, respectively). In addition, cubic spline regression demonstrated that mortality sharply increased at a fibrinogen level of approximately <200 mg/dL and at an antithrombin activity of approximately <50%. Similarly, the decreased levels of the two markers non-linearly correlated with the elevation of DIC score. ConclusionsThe fibrinogen level and antithrombin activity should be reconsidered as unique biomarkers for sepsis and sepsis-induced DIC.

A Scoring System with High-Resolution Computed Tomography to Predict Drug-Associated Acute Respiratory Distress Syndrome: Development and Internal Validation

Drugs can cause acute respiratory distress syndrome (ARDS). However, there is no established clinical prediction rule for drug-associated ARDS (DARDS). We aimed to develop and validate a scoring system for DARDS prediction. We analysed data collected from a prospective, single-centre, cohort study that included ARDS patients. The ARDS diagnosis was based on the American-European Consensus Conference or Berlin definition. Drug-associated acute lung injury (DALI) was defined as previous exposure to drugs which cause ALI and presence of traditional risk factors for ALI. High-resolution computed tomography (HRCT; indicating extent of lung damage with fibroproliferation), Acute Physiology and Chronic Health Evaluation (APACHE) II, and disseminated intravascular coagulation (DIC; indicating multiorgan failure) scores and PaO2/FiO2 were evaluated for their ability to predict DARDS. Twenty-nine of 229 patients had DARDS. The HRCT, APACHE II, and DIC scores and PaO2/FiO2 were assessed. The model-based predicted probability of DARDS fitted well with the observed data, and discrimination ability, assessed through bootstrap with an area under the receiver-operating curve, improved from 0.816 to 0.875 by adding the HRCT score. A simple clinical scoring system consisting of the APACHE II score, PaO2/FiO2, and DIC and HRCT scores can predict DARDS. This model may facilitate more appropriate clinical decision-making.

Study of the prognostic factor of the colon perforation case with the pan‐peritonitis that needed emergency surgery: a single‐center observational study

AimWe divided patients treated with emergency surgery for pan‐peritonitis caused by colon perforation into the survival group and the death group based on outcome at postoperative day 30 and examined the prognostic factors for colon perforation.MethodsThe prognostic factors for colon perforation in 76 consecutive patients who underwent emergency surgery at Kansai Medical University Hospital (Hirakata, Japan) from April 2011 to March 2017 were investigated based on outcome at postoperative day 30.ResultsThe average age of the 76 patients (41 men/35 women) was 73 years, and the causative disease of colon perforation was malignant/benign in 18/58 cases, with ileocecal perforation site in 8 cases, ascending colon in 6, transverse colon in 2, descending colon in 4, sigmoid colon in 49, and rectum in 7. All patients received laparotomy with irrigation drainage, and 9 patients (11.8%) were dead at 30 days. Upon comparing the 67 survivors with the 9 dead patients, we recognized a significant difference on preoperative spread of ascites on computed tomography (CT) (P = 0.002) in univariate analysis and on acute disseminated intravascular coagulation (DIC) score (odds ratio 2.289; 95% confidence interval, 1.188–4.410; P = 0.013) in multivariate analysis.ConclusionIn our hospital, the preoperative acute DIC score was found to be a prognostic factor for colon perforation accompanied by pan‐peritonitis. Appropriate evaluation of the spread of ascites on the preoperative CT might also help predict patient prognosis.

A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study.

AimThe purpose of this study was to determine the prognostic factors of non‐occlusive mesenteric ischemia (NOMI) and to examine treatment strategies that could improve its prognosis.MethodsWe retrospectively identified 30 patients who underwent emergency laparotomy for NOMI in Kansai Medical University Hospital (Hirakata, Japan) from April 2013 to December 2017. We examined prognostic factors related to discharge outcome and also examined the prognostic impact of open abdominal management and second look operation strategy (OSS) by dividing the patients into the non‐OSS group and the OSS group.ResultsThe primary end‐point was a prognostic factor for outcome at discharge of the 30 patients. The outcome at discharge was compared between the survival group and the death group. Multivariate analysis was undertaken on two items from the univariate analysis that showed a significant difference (computed tomography findings of intestinal pneumatosis and acute disseminated intravascular coagulation [DIC] score). As a result, there was a significant difference in the factors of intestinal pneumatosis (odds ratio = 0.054; 95% confidence interval, 0.005–0.607; P = 0.018) and DIC score (odds ratio = 1.892; 95% confidence interval, 1.077–3.323; P = 0.027). The secondary end‐point was the treatment outcome before and after the application of OSS. Operation time was significantly shorter and the amount of bleeding was also significantly less in the OSS group.ConclusionComputed tomography findings of intestinal pneumatosis and the acute disseminated intravascular coagulation score were found to be prognostic factors for survival in patients with NOMI. Aggressive laparotomy to determine the definitive diagnosis is needed and OSS could be useful to improve patient prognosis for survival from NOMI.

SOFA coagulation score and changes in platelet counts in severe acute kidney injury: Analysis from the randomized evaluation of normal versus augmented level (RENAL) study.

To evaluate the prognostic value of baseline SOFA coagulation score (SOFA-CS) and change in platelet counts in patients with severe acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). We performed a secondary analysis from the Randomized Evaluation of Normal versus Augmented Level of RRT (RENAL) study. The primary endpoint was all-cause mortality at 90 days after randomization. The association between baseline SOFA-CS, changes in platelet counts, process of care, and clinical outcomes were analyzed using multivariate Cox model adjusted for baseline variables. The complete SOFA-CS data were available in 1454 out of 1508 patients from the RENAL study. Among them, 708 patients had an abnormal SOFA-CS (defined as SOFA-CS ≥ 1), while 746 patients had normal SOFA-CS at baseline (SOFA-CS = 0). An abnormal SOFA-CS was independently associated with an increased risk of death at 90 days (HR = 1.27, 95% CI = 1.05-1.53, P = 0.015). An abnormal SOFA-CS was associated with prolonged length of ICU stay and duration of mechanical ventilation as well. Furthermore, there was no significant association between changes in platelet counts in patients who survived beyond 4 days and 90 day mortality (HR = 1.26, 95% CI = 0.29-5.56, P = 0.76). However, on multivariable analysis a decline of ≥60% (HR = 1.93, 95% CI = 1.23-3.05, P = 0.004) was associated with 90 day mortality in patients who survived beyond the first 4 days. In the RENAL study, thrombocytopaenia is a common phenomenon in patients with severe AKI receiving CRRT. An abnormal baseline SOFA-CS and reductions in platelet counts were associated with increased mortality at 90 days.

A case of subacute-onset myelodysplastic syndrome with infection mimicking thrombotic thrombocytopenic purpura: a case report with literature review

BackgroundSchistocytosis, which is often observed in thrombotic thrombocytopenic purpura (TTP) patients, is a rare complication in myelodysplastic syndrome (MDS) patients.Case presentationWe report on a 59-year-old man with progressive anemia and thrombocytopenia. Schistocytes were observed in his peripheral blood; consciousness disturbance, renal insufficiency, and fever were subsequently observed, fulfilling the classic pentad of TTP. He also showed massive hematuria, headache, chest pain, and abdominal pain, and brain magnetic resonance imaging scan demonstrated small infarctions. Cefmetazole was not effective, and there was no focus of infection. Disseminated intravascular coagulation (DIC) score was low at that time. We suspected TTP, and therapeutic plasma exchange was initiated. Simultaneously, antibiotic was changed to piperacillin/tazobactam. After the initiation of those treatments, his general condition improved. ADAMTS13 activity did not decrease significantly; therefore, we stopped the therapeutic plasma exchange. His D-dimer level increased and antithrombin level decreased. Heparin treatment was initiated; however, anemia and thrombocytopenia persisted. Bone marrow examinations revealed dyspoiesis in all cell lines, and a complex karyotype indicated a high risk of MDS. His TTP-like condition relapsed; again, piperacillin/tazobactam was effective. Enterococcus faecalis and Haemophilus influenzae were detected in urine culture later. Infection and/or DIC superimposed on MDS might be involved in the pathophysiology of this case.ConclusionsIt should be noted that subacute-onset of MDS with infection can mimic TTP.

Prospective randomized multicenter study to demonstrate the benefits of haemodialysis without acetate (with citrate): ABC-treat Study. Acute effect of citrate

IntroductionDialysis fluid (DF), an essential element in hemodialysis (HD), is manufactured in situ by mixing three components: treated water, bicarbonate concentrate and acid concentrate. To avoid the precipitation of calcium and magnesium carbonate that is produced in DF by the addition of bicarbonate, it is necessary to add an acid. There are 2 acid concentrates that contain acetate (ADF) or citrate (CDF) as a stabilizer. ObjectiveTo compare the acute effect of HD with CDF vs. ADF on the metabolism of calcium, phosphorus and magnesium, acid base balance, coagulation, inflammation and hemodynamic stability. MethodsProspective, multicenter, randomized and crossed study, of 32 weeks duration, in patients in three-week HD, AK-200-Ultra-S or Artis monitor, 16 weeks with ADF SoftPac®, prepared with 3mmol/L of acetate, and 16 weeks with CDF SelectBag Citrate®, with 1mmol/L of citrate. Patients older than 18 years were included in HD for a minimum of 3 months by arteriovenous fistula. Epidemiological, dialysis, pre and postdialysis biochemistry, episodes of arterial hypotension, and coagulation scores were collected monthly during the 8 months of the study. Pre and post-dialysis analysis were extracted: venous blood gas, calcium (Ca), ionic calcium (Cai), phosphorus (P), magnesium (Mg) and parathyroid hormone (PTH) among others.ClinicalTrials.gov NCT03319680. ResultsWe included 56 patients, 47 (84%) men and 9 (16%) women, mean age: 65.3 (16.4) years, technique HD/HDF: 20 (35.7%)/36 (64.3%).We found differences (p<0.05) when using the DF with citrate (C) versus acetate (A) in the postdialysis values of bicarbonate [C: 26.9 (1.9) vs. A: 28.5 (3)mmol/L], Cai [C: 1.1 (0.05) vs. A: 1.2 (0.08)mmol/L], Mg [C: 1.8 (0.1) vs A: 1, 9 (0.2)mg/dL] and PTH [C: 255 (172) vs. 148 (149)pg/mL]. We did not find any differences in any of the parameters measured before dialysis. Of the 4416 sessions performed, 2208 in each group, 311 sessions (14.1%) with ADF and 238 (10.8%) with CDF (p<0.01), were complicated by arterial hypotension. The decrease in maximum blood volume measured by Hemoscan® biosensor was also lower [−3.4 (7.7) vs −5.1 (8.2)] although without statistical significance. ConclusionDialysis with citrate acutely produces less postdialysis alkalemia and significantly modifies Ca, Mg and PTH. CDF has a positive impact on hemodynamic tolerance.

The impact of the abruption severity and the onset-to-delivery time on the maternal and neonatal outcomes of placental abruption

Objective: We examined the impact of the abruption severity and the onset-to-delivery time on the maternal and neonatal outcomes of cases of clinically diagnosed placental abruption (PA).Material and methods: We investigated 84 patients who were diagnosed with PA at our hospital from January 2009 to September 2017. We classified the patients with PA into three groups based on the extent of the abruption: (1) mild abruption, <20%; (2) moderate abruption, 20–49%; (3) severe abruption, ≥50%, which was defined by the attending obstetricians at the time of delivery. The neonatal outcome was measured by the umbilical artery pH and the maternal outcome was measured by the obstetric disseminated intravascular coagulation score (DIC score).Results: The rate of hypertensive disorders of pregnancy in the moderate abruption group was significantly lower than that in other groups (p = .010). The umbilical artery pH was below 7.00 in 29 cases. The umbilical artery pH of the severe abruption group (6.92) was the lowest and was significantly lower in comparison to other groups (mild group [7.24], p < .001; moderate group [7.11], p < .05). There was a significant correlation between the onset-to-delivery time and the umbilical artery pH in the moderate group (R = −0.43). The maternal DIC scores in the three groups did not differ to a statistically significant extent.Conclusions: The severity of placental separation is significantly correlated with poor neonatal outcomes and there was a significant negative correlation between the onset-to-delivery time and the umbilical artery pH in moderate abruption.

Hypercoagulability and the risk of recurrence in young women with myocardial infarction or ischaemic stroke: a cohort study

BackgroundWe aimed to investigate the role of hypercoagulability on the risk of lifetime cardiovascular recurrences after myocardial infarction or ischaemic stroke.MethodsYoung women (< 50 years) with either myocardial infarction (n = 197) or ischaemic stroke (n = 107) were followed between 1995 and 2012 in the RATIO follow-up study. To determine whether hypercoagulability affects the risk or recurrence, a coagulation score based on acquired and inherited markers was compiled and used in a quartile analysis. Hazard ratios (HRs) obtained from Cox proportional models and adjusted for several cardiovascular risk factors were used to compare quartiles of the coagulation score for the risk of recurrence.ResultsDuring a median follow-up of 19 years, 59 cardiovascular recurrences occurred. In patients with myocardial infarction no association was found between a high prothrombotic score and recurrences (highest quartile vs lowest quartile HR 0.7, 95% CI, 0.3–1.8). Conversely, ischaemic stroke patients with a high prothrombotic score showed a doubling in risk of long-term cardiovascular recurrences (HR 1.9, 95% CI 0.6–6.3) compared with ischaemic stroke patients and low levels of the score, with a dose response relationship.ConclusionsAn increased coagulation tendency might be associated with long-term cardiovascular risk in women with ischaemic stroke, but not in women with myocardial infarction.

Markers of Fibrinolysis in Indian Patients with Isolated Head Trauma.

Context:Head injury causes disseminated intravascular coagulation as the most severe complication which is associated with high mortality. Elevated levels of markers of fibrinolysis such as D-dimer and fibrinopeptide A (FPA) have been correlated with poor outcome in these patients.Aim:The study aimed to correlate the levels of plasma fibrinogen, D-dimer, and FPA with outcome in patients with isolated head trauma.Settings and Design:This cross-sectional descriptive study was conducted in the Departments of Pathology and Neurosurgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, on 100 patients admitted within 12 h of isolated head trauma.Subjects and Methods:Plasma fibrinogen, D-dimer, and FPA were measured in 100 patients admitted within 12 h of isolated head trauma. While plasma fibrinogen and D-dimer were estimated in all patients, FPA was measured in 45 patients.Statistical Analysis:SPSS (20.2) software was used for mean, standard deviation, and median values of the quantitative parameters, and for all qualitative parameters, their frequencies were obtained. P < 0.05 was considered significant.Results:Elevated D-dimer (>250 ng/ml) and FPA (>3 ng/ml) were observed in 64% and 91.1% patients, respectively. Both D-dimer and FPA were elevated in 66.6% of patients. Disseminated intravascular coagulation (DIC) score, calculated using standard criteria, was ≥5 in 28% of patients indicating overt DIC. Hypofibrinogenemia was observed in 48% of patients. D-dimer, FPA, and DIC score was significantly (P < 0.001) higher and plasma fibrinogen significantly (P < 0.001) lower in nonsurvivors as compared to survivors. Elevated D-dimer and FPA and low fibrinogen levels were seen in patients irrespective of severity of injury.Conclusions:Elevated D-dimer and FPA were frequently observed in patients with isolated head trauma. As these markers rise soon after injury and indicate poor outcome, their measurement will help identify patients who will benefit with additional therapy, thus reducing morbidity and mortality.

Estudio prospectivo aleatorizado multicéntrico para demostrar los beneficios de la hemodiálisis sin acetato (con citrato): Estudio ABC-treat. Efecto agudo del citrato

IntroductionDialysis fluid (DF), an essential element in hemodialysis (HD), is manufactured in situ by mixing three components: treated water, bicarbonate concentrate and acid concentrate. To avoid the precipitation of calcium and magnesium carbonate that is produced in DF by the addition of bicarbonate, it is necessary to add an acid. There are 2 acid concentrates that contain acetate (ADF) or citrate (CDF) as a stabilizer. ObjectiveTo compare the acute effect of HD with CDF vs. ADF on the metabolism of calcium, phosphorus and magnesium, acid base balance, coagulation, inflammation and hemodynamic stability. MethodsProspective, multicenter, randomized and crossed study, of 32 weeks duration, in patients in three-week HD, AK-200-Ultra-S or Artis monitor, 16 weeks with ADF SoftPac®, prepared with 3mmol/L of acetate, and 16 weeks with CDF SelectBag Citrate®, with 1mmol/L of citrate. Patients older than 18 years were included in HD for a minimum of 3 months by arteriovenous fistula. Epidemiological, dialysis, pre and postdialysis biochemistry, episodes of arterial hypotension, and coagulation scores were collected monthly during the 8 months of the study. Pre and post-dialysis analysis were extracted: venous blood gas, calcium (Ca), ionic calcium (Cai), phosphorus (P), magnesium (Mg) and parathyroid hormone (PTH) among others.ClinicalTrials.gov NCT03319680. ResultsWe included 56 patients, 47 (84%) men and 9 (16%) women, mean age: 65.3 (16.4) years, technique HD/HDF: 20 (35.7%)/36 (64.3%).We found differences (p<0.05) when using the DF with citrate (C) versus acetate (A) in the postdialysis values of bicarbonate [C: 26.9 (1.9) vs. A: 28.5 (3) mmol/L], Cai [C: 1.1 (0.05) vs. A: 1.2 (0.08) mmol/L], Mg [C: 1.8 (0.1) vs A: 1, 9 (0.2) mg/dL] and PTH [C: 255 (172) vs. 148 (149) pg/mL]. We did not find any differences in any of the parameters measured before dialysis. Of the 4,416 sessions performed, 2,208 in each group, 311 sessions (14.1%) with ADF and 238 (10.8%) with CDF (p<0.01), were complicated by arterial hypotension. The decrease in maximum blood volume measured by Hemoscan® biosensor was also lower [−3.4 (7.7) vs −5.1 (8.2)] although without statistical significance. ConclusionDialysis with citrate acutely produces less postdialysis alkalemia and significantly modifies Ca, Mg and PTH. CDF has a positive impact on hemodynamic tolerance.

Value of APACHE.II score and DIC score in predicting the death of patients with heat stroke

Objective: To investigate the predictive values of the acute physiology and chronic health evaluation II (APACHE.II) score and disseminated intravascular coagulation (DIC) score on death in patients with heat stroke. Methods: A total of 76 patients with heat stroke who were treated in Emergency Department of Harrison International Peace Hospital from June 2013 to September 2017 were studied. According to the outcome of patients, we distributed the patients to death group and survival group. APACHE.II score and DIC score were calculated according to the clinical data and the test results at admission. Evaluate the correlation between the two indicators associated with death. Results: There were 76 patients, with 23 deaths (30.3%) and 53 survivors (69.7%) . The APACHE-II score and DIC score were 26.26±6.48 and 4.00±1.38 in the death group.significantly higher than 20.74±4.17 and 2.28±1.21 in the survival group, and there were significant difference (P< 0.01) . The APACHE. II score was positively correlated with the DIC score, and the higher the score, the higher the mortality rate.Both indicators are significant for the Logitic regression analysis of death (P<0.01) .The sensitivity and specificity of the APACHE.II score were 65.2% and 81.1% in prediction of mortality, The sensitivity and specificity of DIC score were 65.2% and 84.9% in prediction of mortality. The specificity of the APACHE II score plus DIC score were higher than that of single APACHE. II score or DIC score in prediction of mortality (P<0.05) . Conclusion: The APACHE.II score and DIC score are significantly increased in the early stage of the patients with heat stroke, and the APACHE. II score combined with DIC score may improve the value in prediction of mortality with heat stroke.

Coagulation Derangements in Patients With Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation

Extracorporeal cardiopulmonary resuscitation (eCPR) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is gaining importance as a rescue therapy for refractory cardiac arrest. VA-ECMO, especially in the setting of eCPR, is plagued by hemorrhagic and thromboembolic complications. The authors' aims were to describe the coagulation profile in refractory cardiac arrest and assess its prognostic role. Single-center retrospective study. Cardiac surgical intensive care unit of a university hospital. One hundred eighty-eight patients treated with eCPR for intra-hospital and out-of-hospital refractory cardiac arrest, between 2008 and 2017. The authors retrospectively analyzed data from the first blood sample drawn during cannulation for VA-ECMO to understand the association of coagulation parameters with survival to hospital discharge, number of blood components transfused, anticoagulation therapy, serum lactate levels, no-flow time, and low-flow time. Platelet count was 126 ± 79 × 109/L and in 17% of the population it was lower than 50 × 109/L, prothrombin time was 3.22 ± 4.01, activated partial thromboplastin time was 117 ± 78 seconds, fibrinogen was 186 ± 148 mg/dL, antithrombin was 47 ± 16%, and D-dimer was ≥2-fold the normal upper limit in 95% of patients. Fifty percent of patients had a disseminated intravascular coagulation (DIC) score ≥6 (52% among out-of-hospital cardiac arrest, 33% among in-hospital cardiac arrest), according to the criteria of the Japanese Society on Thrombosis and Hemostasis (2016). The median DIC score was 5.5 points (interquartile range 4-8), significantly different between survivors and nonsurvivors (4 [3-6] v 6 [4-8], p = 0.007). Every DIC score point contributed to the mortality risk (OR 1.34, 95% CI 1.09-1.67, p = 0.006). Patients with overt DIC less frequently received anticoagulants (28.6% v 55.9%, p = 0.002), started anticoagulant therapy later (12 [10-23] v 8.5 [5-12] hours, p = 0.045), and received a larger quantity of blood products (11 [4-23] v 3 [0-8.5] units, p < 0.0001). Coagulation derangements are frequent in patients with refractory cardiac arrest and have important consequences for eCPR management for anticoagulant therapy and blood product transfusion. The presence of DIC diagnostic criteria should be considered among the prognostic factors in this population of patients.

Clinical differences between pulmonary and extrapulmonary acute respiratory distress syndrome: a retrospective cohort study of prospectively collected data in Japan.

Although acute respiratory distress syndrome (ARDS) reportedly shows various clinical phenotypes with different risk and prognostic factors, few studies have assessed the clinical features and prognosis of pulmonary and extrapulmonary ARDS. The aim of the present study was to investigate clinical differences between pulmonary and extrapulmonary ARDS. In total, 200 patients who met the Berlin criteria and were diagnosed with ARDS between October 2004 and September 2017 were included. We classified the patients into pulmonary and extrapulmonary ARDS groups. Both groups were assessed for 60-day mortality, duration of ventilation, and other clinical features. There were 150 and 50 patients in the pulmonary and extrapulmonary ARDS groups, respectively. The two groups showed no significant differences in any assessment parameters except the serum lactate dehydrogenase (LDH) level, which was higher in the extrapulmonary ARDS group (P=0.01). After adjustment for potentially confounding covariates, there were no significant differences in 60-day mortality (P=0.99) and the duration of ventilation (P=0.45) between the two groups. Mortality was significantly associated with the disseminated intravascular coagulation (DIC) score, high-resolution computed tomography (HRCT) score, and serum LDH level in the pulmonary ARDS group and the DIC score and HRCT score in the extrapulmonary ARDS group. Pulmonary and extrapulmonary ARDS may be comparable in terms of the prognosis and duration of ventilation. DIC and HRCT scores may be common clinical predictors of mortality with ARDS.

Post-cardiotomy venovenous extracorporeal membrane oxygenation without heparinization

We present the cases of eight patients (mean age 75 years; EuroSCORE II 17.0 ± 22.0) who underwent post-cardiotomy venovenous extracorporeal membrane oxygenation (ECMO) without heparinization due to serious bleeding. Three liver cirrhosis, two chronic hemodialysis, three redo sternotomy, and two urgent surgery cases were included. Respiratory ECMO Survival Prediction score was − 5.1 ± 4.2 (estimated survival rate: approximately 30%). Mean ECMO duration was 14 days with 9 circuit exchanges. Five patients were weaned from ECMO and three were discharged alive at 90 days (survival 37.5%). There was a case of pump-head thrombosis requiring urgent circuit exchange. All experienced bleeding complications without clinically apparent pulmonary thromboembolism. Disseminated Intravascular Coagulation scores (Pre 1.3 ± 0.8 vs. Post 3.8 ± 1.7; p < 0.05) significantly increased (N = 6). Post-cardiotomy ECMO without heparinization facilitated patient rescue at a reasonable survival rate. However, bleeding complications were still observed. More sophisticated management protocols are warranted.

Performance of 5 disseminated intravascular coagulation score systems in predicting mortality in patients with severe trauma.

The present study aimed to analyze and compare the prognostic performances of the Japanese Ministry of Health and Welfare (JMHW) score, the Korean Society on Thrombosis and Hemostasis (KSTH) score, the International Society on Thrombosis and Haemostasis (ISTH) score, the Japanese Association for Acute Medicine (JAAM) score, and the revised JAAM (rJAAM) score, for 28-day mortality in severe trauma.This retrospective observational study included patients admitted for severe trauma between 2012 and 2015. Receiver operating characteristics analysis was performed to examine the prognostic performance of the 5 different DIC score systems. The primary outcome was 28-day mortality following an injury.Of the 1266 patients included in the study, 28-day mortality rate was 19.7% (n = 249). The area under the curves (AUCs) of JMHW, KSTH, ISTH, JAAM, and rJAAM scores for 28-day mortality were 0.751 [95% confidence interval (95% CI), 0.726–0.775], 0.726 (95% CI, 0.701–0.750), 0.700 (95% CI, 0.674–0.725), 0.673 (95% CI, 0.646–0.699), and 0.676 (95% CI, 0.649–0.701), respectively. The AUC of JMHW score was significantly different from those of the other score systems. Fibrinogen levels ≤1.0 g/L [odds ratio (OR), 1.824; 95% CI, 1.029–3.232] and 1.0 to 1.5 g/L (OR, 1.697; 95% CI, 1.058–2.724) were independently associated with 28-day mortality compared with fibrinogen level above 1.5 g/L.JMHW score has the highest prognostic performance for 28-day mortality among DIC score systems in severe trauma. Fibrinogen level seemed to have a role in greater discrimination of JMHW scores than the other DIC score systems.

Plasma myeloperoxidase-conjugated DNA level predicts outcomes and organ dysfunction in patients with septic shock

BackgroundRecent studies have suggested that excessive formation of neutrophil extracellular traps (NETs) plays a critical role in the pathogenesis of sepsis. Although elevation of the plasma level of cell-free DNA (cf-DNA) has been reported in sepsis patients, there has been little direct measurement of circulating free NETs such as myeloperoxidase-conjugated DNA (MPO-DNA). The objectives of this study were to detect NETs in the bloodstream of patients with septic shock, and to assess the correlations of circulating NET levels with organ dysfunction, disease severity, and mortality.MethodsFifty-five patients with septic shock admitted to the intensive care units (ICUs) of 35 Japanese hospitals were studied. Septic shock was diagnosed according to the 1997 definition of the American College of Chest Physicians/Society of Critical Care Medicine. To detect circulating NETs, plasma levels of MPO-DNA and cf-DNA were measured by sandwich enzyme-linked immunosorbent assay and by fluorometric assay on days 1, 3, and 7 after the onset of septic shock. Physiological and mortality data were collected from the clinical database.ResultsOn days 1, 3, and 7, the patients showed a marked increase in plasma MPO-DNA levels compared with healthy volunteers, whereas the plasma cf-DNA level was only increased significantly on day 1 and then decreased rapidly. A high MPO-DNA level on days 3 and 7 were associated with 28-day mortality.On days 3 and 7, the MPO-DNA levels were inversely correlated with both the mean arterial pressure and the PaO2/FIO2 ratio, whereas the cf-DNA level was not correlated with either parameter. There was a positive correlation between the plasma MPO-DNA level and the sepsis-related organ failure assessment score on days 3 and 7. Neither cf-DNA nor MPO-DNA levels were correlated with the disseminated intravascular coagulation (DIC) score or the platelet count.ConclusionThe increase in circulating MPO-DNA in patients with septic shock indicates acceleration of NET formation in the early stages of sepsis. High MPO-DNA levels are associated with the severity of organ dysfunction and 28-day mortality due to septic shock, but not with the DIC score. These results suggest that excessive NET formation contributes to the pathogenesis of septic shock.

Evaluation of disseminated intravascular coagulation scores in critically ill pediatric patients with septic shock

PurposeTo evaluated the outcome predictability of DIC scores in critically ill children with septic shock. Materials and methodsPediatric patients with septic shock who were admitted to the pediatric intensive care unit of a tertiary care children's hospital between January 2013 and December 2017 were enrolled. We analyzed the association between DIC and clinical outcomes. DIC was diagnosed based on the International Society on Thrombosis and Hemostasis (ISTH), Japanese Association for Acute Medicine (JAAM), and modified JAAM DIC criteria. ResultsAmong the 89 patients, DIC was diagnosed in 66.3%, 61.8%, and 41.6% of patients using the JAAM, modified JAAM, and ISTH DIC criteria, respectively. Overall 28-day mortality was 14.6%. DIC patients had worse outcomes, including a higher 28-day mortality and multiorgan dysfunction syndrome (MODS) than those without DIC. The DIC scores were well correlated with the MODS scores. The JAAM and modified JAAM DIC scores showed good outcome predictability (p < 0.05) with areas under the receiver operating characteristic curve of 0.765 and 0.741, respectively. ConclusionsCritically ill children with septic shock frequently experience DIC. Patients with DIC had worse outcomes than those without DIC. JAAM and modified JAAM DIC scores could be promising outcome predictors in these patients.