Incidence Of Disseminated Intravascular Coagulation Research Articles

Prediction of in-hospital mortality in patients with exertional heatstroke: a 13-year retrospective study

ABSTRACT Hyperactivity of coagulation is common in exertional heatstroke (EHS). Disseminated intravascular coagulation (DIC) is the most severe form of coagulation dysfunction and associated with poor outcome. DIC, temperature and Glasgow coma scale score were identified as independent risk factors for in-hospital mortality by multivariate logistic regression analysis, and we developed a nomogram for predicting in-hospital mortality in a 13-year EHS patient cohort. The nomogram was assessed by calibration curves and bootstrap with 1,000 resamples. The receiver operating characteristic curve was constructed, and the area under the curve (AUC) was compared. Two hundred and ten patients were included. The in-hospital mortality was 9.0%, and the incidence of DIC was 17.6%. The AUC of the nomogram was 0.897 (95% CI 0.848–0.935, p < .0001) and was non-inferior to SOFA and APACHE II scores but superior to SIRS score, which were widely-used score systems of disease severity. The nomogram contributed to the adverse outcome prediction of EHS.

Infectious causes and management of Japanese spotted fever and severe fever thrombocytopenia syndrome in Ehime prefecture

Objectives We investigated the infectious causes and management of Japanese spotted fever (JSF) and severe fever thrombocytopenia syndrome (SFTS), which are usually tick-borne infections, at a public health center in Ehime prefecture.Methods The doctor diagnosing JSF and SFTS at the public health center reported the infectious cases using the questionnaire based on the Ehime Epidemiological Surveillance of Infectious Diseases Program.Results There were 91 cases of JSF reported from August 2003, accounting for 56.5% of the whole Ehime prefecture. Since 67.0% of the JSF patients resided near the mountains with citrus cultivations, there were high chances of contact with ticks during farm work or their daily routine even if they did not visit the mountain areas. The distribution of the occupations of the JSF patients was as follows: citrus cultivator, 31.9%; farmer, 14.3%; and retired, 26.4%. The incidence of various clinical symptoms in the JSF patients was as follows: fever and systemic erythema, 100%; tick bite, 73.6%; liver dysfunction, 69.2%; disseminated intravascular coagulation (DIC), 14.3%; and neurological symptoms, 11.0%. The mortality rate was 1.1%. The incidence of DIC, which was considered a severe condition, was significantly low in patients with confirmed tick bites. There were 14 cases of SFTS reported from December 2013, accounting for 42.4% of the whole Ehime prefecture. Notably, 85.7% of the SFTS patients resided in the mountains. Moreover, 85.7% of the SFTS patients were retired. The incidence of various clinical symptoms in the SFTS patients was as follows: fever and marked leucopenia and thrombocytopenia, 100%; tick bite, 57.1%; diarrhea, 71.4%; neurological symptoms, 57.1%; and bleeding tendency, 42.9%. The mortality rate was 35.7%, and the average number of days from onset to death was 11.2 days.Conclusion Since this region is one of the leading citrus producing areas in Ehime prefecture, JSF is considered an occupational disease. It is frequently caused by tick bites while working in the mountain areas of citrus cultivations. Hence, citrus growers should be cautious of tick-borne infections. Recently, the number of JSF cases has been gradually decreasing due to awareness and education of the inhabitants. Currently, SFTS is considered a category IV infection disease, but it can rapidly lead to death after the onset of hemophagocytic syndrome. Therefore, doctors should immediately transfer the patients diagnosed with SFTS to a hospital with an intensive care unit.

Radiologic Intervention of Internal Iliac Artery Occlusion During Cesarean Section for Dangerous Placenta Previa

Objective: The cesarean section of dangerous placenta previa always faces the problem of massive hemorrhage. The aim of this study was to analyze the clinical effect of internal iliac artery occlusion combined with obstetric autotransfusion in cesarean section of dangerous placenta previa. Method: From November 2017 to November 2019, 20 patients with placenta previa undergoing cesarean section in our hospital were selected. According to the preoperative MRI and ultrasound diagnosis, the amount of bleeding was evaluated and divided into observation group (n = 6) and control group (n = 14). All patients underwent routine cesarean section and prepared the obstetric autotransfusion device. In the observation group, the internal iliac artery balloon was placed under DSA before operation. After the fetus was taken out, the internal iliac artery was blocked. The internal iliac artery occlusion was not needed in the control group. The total length of stay, Apgar score, the incidence of disseminated intravascular coagulation (DIC), hemorrhagic shock, postoperative infection and renal dysfunction were compared between the two groups. Result: Compared with the relative data in control group, the operation time and postoperative hospital stay of the observation group were significantly shorter, the intraoperative blood loss and blood transfusion were significantly lesser, and the hemoglobin difference before and after operation was significantly lesser. There was no significant difference in the incidence of DIC, hemorrhagic shock, postoperative infection and renal dysfunction between two groups; There was no significant difference in neonatal body mass, Apgar score at 1 min and 5 min. Conclusion: The internal iliac artery occlusion can effectively reduce the amount of bleeding in delivery, promote the recovery of negligence, and have no adverse effect on complications and neonatal outcome.

Radiologic Intervention of Internal Iliac Artery Occlusion During Cesarean Section for Dangerous Placenta Previa

Objective: The cesarean section of dangerous placenta previa always faces the problem of massive hemorrhage. The aim of this study was to analyze the clinical effect of internal iliac artery occlusion combined with obstetric autotransfusion in cesarean section of dangerous placenta previa. Method: From November 2017 to November 2019, 20 patients with placenta previa undergoing cesarean section in our hospital were selected. According to the preoperative MRI and ultrasound diagnosis, the amount of bleeding was evaluated and divided into observation group (n = 6) and control group (n = 14). All patients underwent routine cesarean section and prepared the obstetric autotransfusion device. In the observation group, the internal iliac artery balloon was placed under DSA before operation. After the fetus was taken out, the internal iliac artery was blocked. The internal iliac artery occlusion was not needed in the control group. The total length of stay, Apgar score, the incidence of disseminated intravascular coagulation (DIC), hemorrhagic shock, postoperative infection and renal dysfunction were compared between the two groups. Result: Compared with the relative data in control group, the operation time and postoperative hospital stay of the observation group were significantly shorter, the intraoperative blood loss and blood transfusion were significantly lesser, and the hemoglobin difference before and after operation was significantly lesser. There was no significant difference in the incidence of DIC, hemorrhagic shock, postoperative infection and renal dysfunction between two groups; There was no significant difference in neonatal body mass, Apgar score at 1 min and 5 min. Conclusion: The internal iliac artery occlusion can effectively reduce the amount of bleeding in delivery, promote the recovery of negligence, and have no adverse effect on complications and neonatal outcome.

Identification of hemostatic markers that define the pre‐DIC state: A multi‐center observational study

BackgroundA limitation of diagnostic scoring systems for disseminated intravascular coagulation (DIC) is that once DIC is identified, it may be in a state of irreversible deterioration. ObjectivesTo identify hemostatic markers that can identify the pre‐DIC state. MethodsThis was a multi‐center observational study of 357 septic patients. The incidence of DIC was determined using the International Society on Thrombosis and Haemostasis (ISTH) DIC Score. Markers of interest include components of the DIC score: protein C (PC), antithrombin (AT), and citrullinated histones (H3Cit), which is a marker of NETosis. ResultsOut of 357 sepsis patients, 236 patients did not develop DIC (without‐DIC), 79 patients had DIC on Day 1 (overt‐DIC), and 42 patients developed DIC after Day 1 (pre‐DIC). Compared to without‐DIC patients, pre‐DIC patients had decreased platelet count, increased international normalized ratio (INR), decreased PC and AT, and increased H3Cit. In contrast, D‐dimer and fibrinogen levels did not differ between pre‐DIC and without‐DIC patients. Using receiver operating characteristics (ROC) analysis, we found that platelet count and INR in combination with PC and AT could discriminate pre‐DIC from without‐DIC. The area under the curve in the ROC analysis was 0.83 (95% confidence interval, 0.76 to 0.89). ConclusionOur study suggests that platelets and INR in combination with PC and AT can identify the pre‐DIC state in septic patients. In contrast, D‐dimer increased and fibrinogen decreased in the late (ie, overt) stages of DIC. Our data also suggest that NETosis contributes to the onset of DIC in sepsis.

Focus on coronavirus disease 2019 associated coagulopathy.

Focus on coronavirus disease 2019 associated coagulopathy.

Prevalence and Impact of Coagulation Dysfunction in COVID-19 in China: A Meta-Analysis.

Background The aim of this meta-analysis is to assess the prevalence of coagulation dysfunction in Chinese COVID-19 patients and to determine the association of coagulopathy with the severity and prognosis of COVID-19. Methods A meta-analysis of the prevalence of different abnormal coagulation indicators in COVID-19 patients in China was performed. The difference of coagulation indicators and the incidence of DIC were compared between severe cases and nonsevere cases as well as nonsurvivors and survivors, respectively. Results A total of 22 Chinese studies involving 4,889 confirmed COVID-19 inpatients were included. The average D-dimer value of COVID-19 patients is 0.67 µg/mL (95% confidence interval [CI]: 0.56–0.78), and 29.3% (95% CI: 20.1–38.5%) of patients showed elevated D-dimer values. Severe patients had significantly higher D-dimer levels and prolonged prothrombin time (PT) compared with nonsevere patients. Nonsurvivors had significantly higher D-dimer levels, prolonged PT, and decreased platelet count compared with survivors. In total, 6.2% (95% CI: 2.6–9.9%) COVID-19 patients were complicated by disseminated intravascular coagulation (DIC), in which the log risk ratio in nonsurvivors was 3.267 (95% CI: 2.191–4.342, Z = 5.95, p < 0.05) compared with that in survivors. Conclusion The prevalence of coagulopathy in Chinese COVID-19 inpatients is high, and both the abnormal coagulation indicators and DIC are closely associated with the severity and poor prognosis of these COVID-19 patients. Therefore, attention should be paid to coagulation dysfunction in COVID-19 patients. Closely monitoring of coagulation indicators and application of appropriate anticoagulation may improve the prognosis of COVID-19 inpatients in China.

Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta.

To evaluate the efficacy and safety of prophylactic uterine artery embolization (UAE) during cesarean delivery for women with placenta previa complicated by placenta accreta. A retrospective analysis of women with placenta previa admitted to The Second Affiliated Hospital of Soochow University, Suzhou, China, for elective cesarean between February 2003 and July 2016. Postpartum estimated blood loss, blood transfusion, hysterectomy, disseminated intravascular coagulation (DIC) incidence, intensive care unit (ICU) duration, and postoperative stay were compared between control women who underwent cesarean delivery only and women who underwent prophylactic intraoperative UAE during cesarean. There were 28 and 26 women in the UAE and control group, respectively. There were no differences in hysterectomy incidence (P=0.291), or duration of ICU stay (P=0.085), or postoperative hospitalization (P=0.668) between the groups; however, the incidence of DIC was lower in the UAE group (P=0.035). Mean estimated blood loss (P=0.018) and blood transfusion (P=0.011) were also lower in the UAE group. No serious complications were associated with the endovascular procedures. Prophylactic intraoperative UAE seemed to effectively reduce blood loss, need for blood transfusion, and incidence of DIC among women with placenta previa complicated by placenta accreta.

Incidence and In-Hospital Mortality of Neonatal Disseminated Intravascular Coagulation in Japan: An Observational Study of a Nationwide Hospital Claims Database.

This study aimed to estimate the incidence and prognosis of neonatal disseminated intravascular coagulation (DIC) in Japan by analyzing data retrieved from a national administrative database. Clinically, the prognosis of DIC in neonates is poor, but there is little epidemiological data in Japan. This retrospective observational study identified patients diagnosed with neonatal DIC and who were registered in the Japanese diagnosis procedure combination (DPC) database between April 1, 2014 and March 31, 2016. The patients, who were diagnosed with neonatal DIC, included those with ICD-10 code D65 or P60 in primary and secondary diagnosis, with comorbid conditions existing at admission, and with complications occurring after admission. Of 78,073 neonates admitted to 1,474 neonatal intensive care units, 1,864 (2.4%) were diagnosed with DIC. There was no difference between sexes in incidence of DIC; the incidence of DIC was higher in extremely low birth weight infants (9.8%), and significantly higher than that in normal birth weight infants. The overall mean length of hospital stay was longer in neonates with DIC (69.5 days) than in those without DIC (32.6 days, P < 0.001). The number of deaths was 1,156 (1.5%). In-hospital mortality was significantly higher in neonates with DIC (14.1%) than in those without DIC (1.2%, P < 0.001), especially in premature babies. This nationwide study was the first report to investigate the incidence and in-hospital mortality of neonatal DIC in Japan. Neonatal DIC has a significant impact on prognosis, and its influence is greater in premature than in term infants.

Neutrophil Extracellular Traps in the Development of Sepsis-Induced Disseminated Intravascular Coagulation

Introduction: Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by widespread intravascular activation of coagulation complicating many conditions including sepsis and traumatic injuries. Early recognition and treatment of DIC is of paramount importance. However, to date no useful markers have been identified that can differentiate “pre-DIC” (which is destined to lead to DIC) from “without-DIC” (in which the hypercoagulable state is transient and does not lead to DIC). Activation of neutrophils by inflammatory stimuli or microbes results in the release of neutrophil extracellular traps (NETs). NETs are web-like structures consisting of cell-free DNA (cfDNA), histones, myeloperoxidase (MPO), and anti-microbial proteins. Although NETs aid in the host response to infection by sequestering pathogens, excessive production of NETs can exert collateral damage to the host by activating coagulation, inhibiting fibrinolysis, and causing endothelial cell death. Recently, sepsis-induced DIC has been shown to correlate with circulating levels of DNA-associated MPO, suggesting that the release of NETs by neutrophils plays a critical role in the onset of DIC. Our objective was to attempt to identify a mechanistic role for NETosis in the development DIC in sepsis and use this information to identify ‘pre-DIC’ signatures.Methods: Clinical data and biological samples from 357 septic patients who were part of the DNA as a Prognostic Marker in ICU patient (DYNAMICS) study were used. Incidence of DIC was determined using the International Society on Thrombosis and Haemostasis (ISTH) scoring system on Day 1 and each subsequent day. We quantified levels of Citrullinated Histone H3 (H3Cit), a biomarker of NETosis, as well as levels of cfDNA. We also measured levels of Protein C (PC), a natural anticoagulant that prevents blood clotting in the microcirculation. Increased consumption of PC is a hallmark of sepsis and may lead to microvascular thrombosis and DIC.Results: Of the 357 patients included from the DYNAMICS study, 121 were classified as having DIC during the study period: 79 on Day 1 ('overt-DIC') and 42 on a subsequent day ('pre-DIC'). Baseline characteristics of patients are shown in Table 1. Those with DIC had significantly higher baseline APACHE II scores and were significantly more likely to be on vasopressors at admission or have a history of chronic liver disease. DIC was associated with significantly increased mortality (HR= 2.53; 95% CI = 1.62 - 3.93; p < 0.001) even when age and past medical history were controlled for. Levels of PC were significantly reduced in patients with DIC at all time points compared to those without DIC (p < 0.01). However, cfDNA levels did not differ between patients with and without DIC at any timepoint. As cfDNA may be released by multiple mechanisms and sources, H3 Cit was quantified on Day 1 as a marker of NETosis. Levels of H3 Cit on Day 1 were significantly higher in “pre-DIC” and “overt-DIC” patients compared to those 'without DIC' (p<0.05), non-septic, non-trauma ICU Controls (p<0.01), and healthy volunteers (p<0.001) (Figure 1). With respect to differentiating ‘pre-DIC’ from ‘overt-DIC’, using Day 1 H3 Cit provided an AUC of 0.66 (0.59-0.74). Higher H3 Cit levels were also correlated with lower PC levels in septic patients (r = -0.124; p = 0.02). In a comparison group of non-septic trauma patients also from the DYNAMICS study; (n=6) patients with DIC did not have significantly different Day 1 H3 Cit from (n=25) trauma patients without DIC (p=0.62) or ICU controls (p=0.99).Conclusion: In sepsis, DIC pathophysiology reflects a consumptive process as indicated by reduced PC levels. NETosis may contribute to this process by producing pro-coagulant stimuli and may prove useful in identifying patients who will develop DIC. As a regulated and targetable process investigations involving NETosis may yield therapies for early treatment of DIC in sepsis. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Outcomes of Patients With Septic Shock on Multiple Vasoactive Agents

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Septic shock carries a high mortality rate despite various advances. Vasoactive agents are used to maintain hemodynamics and enhance tissue perfusion. There is limited data on the efficacy of using multiple vasoactive agents in the management of septic shock. METHODS: This is a retrospective cohort study of patients from 04/01/2014 to 12/31/2016 who were identified to have septic shock based on ICD-9/10 codes. Inclusion criteria were age≥18, ICU admission, and treatment with ≥1 vasoactive agents (vasopressor or inotrope, including oral agents). Preliminary analysis was performed on 226 subjects using SAS 9.4. Independent t-test and analysis of variance were performed for continuous variables. Chi-squared and Fisher’s exact tests were performed for categorical variables. The primary outcome was 28-day mortality. Secondary outcomes included ICU length of stay (LOS), days on mechanical ventilation (MV), incidence of disseminated intravascular coagulation (DIC) and incidence of arrhythmias. RESULTS: The overall 28-day mortality rate in this cohort was 52.24%. Patients requiring one, two, and three agents had 28-day mortality rates of 41.35%, 62.69%, and 68.09%, respectively (p=0.0010). Significance remained when adjusted for APACHE II scores (p=0.0043). Those patients on two agents were 2.4 times more likely to die at 28-days compared to one agent (OR=2.346, 95% CI 1.202-4.577, p=0.0124). Those on three vasoactive agents were 3.0 times more likely to have mortality at 28-days (OR=2.991, 95% CI 1.434-6.237, p=0.0035). There was no significant difference in mortality between two and three vasoactive agents (OR=1.275, 95% CI=0.577-2.818, p=0.5468). As compared to those on one agent, those on three agents had increased need for hemodialysis (32.7% vs. 8.74%, p=0.0006), longer days on MV (8.42 vs. 3.47, p=0.0002), and longer ICU LOS (9.51 vs. 6.02, p=0.0273). Patients on 3 agents were 6.52 more likely to have DIC compared to those on 1 agent (OR=6.519, 95% CI 2.72-15.62, p<0.0001). CONCLUSIONS: Patients who required more than one vasoactive agent in the treatment for septic shock had poorer outcomes. With each additional vasoactive agent, there was an increase in 28-day mortality, ICU LOS, days on MV, need for hemodialysis, incidence of DIC, and incidence of arrhythmias. CLINICAL IMPLICATIONS: The higher mortality seen in patients who require multiple vasoactive agents can be a useful prognostic tool for clinicians, especially as it relates to further escalating care and addressing goals of care. DISCLOSURE: The following authors have nothing to disclose: Sung Lee, Boram Kim, Rupa Iyengar, Manideep Duttuluri, Di Pan, Nader Ishak Gabra, Hassan Khouli, Joseph Mathew No Product/Research Disclosure Information

Analysis of empirical treatment for newly diagnosed acute promyelocytic leukemia combined with disseminated intravascular coagulation

This study was aimed to explore the clinical characteristics and optimal therapeutic methods for newly diagnosed acute promyelocytic leukemia (APL) combined with disseminated intravascular coagulation (DIC) so as to guide the clinical therapy. The clinical date and therapeutic outcome of 25 cases of APL combined with DIC treated from January 2008 to March 2013 in our department were analysed retrospectively. The 25 patients were given ATRA 20 mg orally twice a day and arsenic trioxide (ATO) 10 mg intravenously once a day to induce differentiation therapy, the chemotherapy was added after degranulation of promyelocytes. At the same time the platelets, fresh frozen plasma, fibrinogen, cryoprecipitate,prothrombin complex and amino methylbenzoic acid, low molecular weight heparin were given to treat DIC. According to the laboratorial examination of coagulation and fibrinolysis, the medication was adjusted.The white blood cell count, platelet level, prothrombin time (PT), partial thromboplastin time of plasma (APTT), fibrinogen level were detected, and the relation of those factors and age with bleeding severity was analyzed by multivariate manner. The results showed that among 25 patients with APL (low-risk 5 cases, intermediate risk 13 cases and high risk 7 cases), 22 cases combined with DIC, incidence of DIC was 88%. Out of 22 patients with DIC 21 patients (95.5%) were corrected, except 1 case death. After the first course of treatment, 23 cases (92%) gained complete remission (CR) with average CR time 31.8 ± 7.2 days. During the induction of CR, the average platelet transfusion level was 75.68 ± 55.88 U, the RBC level was 8.90 ± 5.69 U, the average level of fresh frozen plasma transfusion of APL patients with DIC was 21.92 ± 19.32 U. The recovery time of platelet level to normal was 29.3 ± 9.3 days, the recovery time of PT, APTT, FDP and fibrinogen to normal were 12.7 ± 9.5 days, 11.6 ± 8.6 days, 16.0 ± 9.3 days and 125.3 ± 85.3 days respectively. The multivariate analysis showed that WBC count at onset was >10 × 10(9)/L and APTT was prolonged. These two factors were main reasons resulting in severe bleeding. It is concluded that the newly diagnosed APL always combined with DIC, therefore in the early phase of disease active transfusion of blood products, application of anti-coagulation and anti-fibrinolytic drugs as well as heparin should be performed; the coagulation function should be as soon as recovered to normal so as to early correct DIC. These measures can significantly decrease the mortality of APL patients resulting from DIC. The hyperleukocytosis and prolonged APTT are the main factors for severe bleeding.

Treatment effects of xuebijing injection in severe septic patients with disseminated intravascular coagulation.

The treatment effects of Xuebijing (XBJ) injection in severe septic patients with disseminated intravascular coagulation (DIC) were investigated in this study. 171 severe septic patients with DIC were divided into the control group (n = 83) or intervention group (n = 88). Routine therapies were administered in both groups, and XBJ injection was administered additionally in the intervention group. Incidence of DIC, clinical severity scores, and coagulation parameters at 7 days after administration of XBJ injection were compared between the two groups, and short-term prognosis was evaluated by 28-day mortality. Compared with the control group, incidence of DIC in the intervention group was significantly lower at 7 days after administration of XBJ injection (P < 0.001). In addition, differences of platelet count and prothrombin time were significantly greater in the intervention group than in the control group (P all <0.05), and similar results were also found for differences of the Mortality in Emergency Department Sepsis score and Acute Physiology and Chronic Health Evaluation II score (P all <0.05). Furthermore, 28-day mortality was significantly lower in the intervention group (P = 0.034). These results demonstrate that XBJ injection can effectively treat DIC caused by severe sepsis and improve short-term prognosis of severe septic patients with DIC.

Disseminated intravascular coagulation in dogs with gastric dilatation-volvulus syndrome

Gastric dilatation and volvulus syndrome is associated with changes in haemostatic profiles. The aims of this study were to compare selected haemostatic and fibrinolytic parameters between healthy dogs and dogs with gastric dilatation and volvulus syndrome, estimate the incidence of disseminated intravascular coagulation (DIC), and determine the most sensitive test for detection of DIC in these patients. Blood was collected from 22&amp;nbsp;dogs with gastric dilatation and volvulus syndrome, and nine healthy control dogs. Platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen concentrations and fibrin/fibrinogen degradation products were measured in all control dogs and patients with gastric dilatation and volvulus syndrome, before and after surgery. Significant differences between control dogs and patients were seen in activated partial thromboplastin time and fibrin/fibrinogen degradation products before surgery and all measured parameters after surgery. The incidence of DIC was 59%. The most sensitive tests for detection of DIC before surgery were those for activated partial thromboplastin time and fibrin/fibrinogen degradation products.

Trends in the Incidence and Outcomes of Disseminated Intravascular Coagulation in Critically Ill Patients (2004-2010): A Population-Based Study

The incidence and outcomes of disseminated intravascular coagulation (DIC) are incompletely defined. Therefore, we aimed to evaluate the trends in incidence and outcomes of critically ill patients with DIC.We conducted a population-based, retrospective cohort study evaluating consecutively admitted adult (≥ 18 years old) critically ill patients with DIC at the Mayo Clinic, Minnesota, from 2004 to 2010. DIC was diagnosed according to the International Society on Thrombosis and Hemostasis' overt DIC algorithm. Patients given a diagnosis of heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, Child Pugh class C, or any known congenital or acquired coagulation disorders were excluded.Of the 8,089 Olmsted County resident ICU admissions, a total of 154 patients met the DIC inclusion criteria. The overall incidence rate of DIC/100,000 person-years decreased from 26.2 (95% CI, 17.1-38.4) in 2004 to 18.6 (95% CI, 11.3-28.7) in 2010. The incidence rate of DIC increased with age in both men and women and was consistently higher in men, with the exception of the age group 18 to 39 years. The incidence rate/100,000 person-years of DIC in men decreased from 41.6 (95% CI, 25.4-64.2) in 2004 to 21.2 (95% CI, 10.6 37.9) in 2010 (P = .01), whereas in women, it did not change significantly (P = .79). The case fatality rate did not change significantly during the study period.The incidence of DIC has decreased over the past decade, significantly in men, although the mortality rate remains the same. This is in agreement with trends in other critical care syndromes and could be attributable to improvements in health care delivery.

Validating the incidence of coagulopathy and disseminated intravascular coagulation in patients with traumatic brain injury – analysis of 242 cases

Objectives: To estimate the incidence of coagulopathy and disseminated intravascular coagulation (DIC) in patients with traumatic brain injury (TBI) and to investigate its relationship to patient outcome.Design: A prospective observational study.Measurements and main results. From January 2007 to June 2009, 242 consecutive adult patients with TBI seen in three independent hospitals were recruited. Glasgow Coma Score (GCS) on admission, platelet counts (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), d-dimer (D-DT) and DIC scores were recorded for each case on admission. Clinical outcome was measured according to the Glasgow Outcome Scale (GOS) at 3 months after injury. Statistical analysis was carried using Student's t-test, one-way analysis of variance (ANOVA), and Tudey test. Coagulation abnormalities were present in approximately 50% of patients with TBI. Prolonged PT and increased D-DT and FIB levels occurred in patients with more severe brain injury and poorer outcome, and these findings were statistically significant.Conclusions: Coagulation changes, particularly the incidence of DIC, may occur within 6 h after TBI and are more pronounced in patients with severe injuries and poor outcome. PT, D-DT levels and more comprehensively a DIC scores may be useful prognostic indicators in patients with TBI.

Heterogeneity in the incidence and clinical manifestations of disseminated intravascular coagulation: a study of 204 cases.

The incidence and clinical manifestations of disseminated intravascular coagulation (DIC) were examined in patients with a range of underlying disorders. Out of 1,882 patients suspected as having DIC, 204 cases were diagnosed as suffering from DIC and included in this study. The underlying disorders experienced by the patients were solid tumors (33.8%), hematologic malignancies (12.7%), aortic aneurysm (10.8%), infections (6.4%), post-operative complications (4.4%), liver disease (2.9%), obstetric disorders (2.5%), and miscellaneous diseases (26.5%). The incidence of DIC was 10.8% out of all patients suspected of having DIC, and the etiologies were 10.9% in solid tumors, 10.1% in hematological malignancies, 20.4% in aortic aneurysm, 12.7% in infections, 15.5% in post-operative complications, 15.8% in liver disease, 3.7% in obstetric disorders, and 9.8% in miscellaneous diseases. The clinical manifestations of DIC patients were varying dependent on their etiologies. Most DIC patients with aortic aneurysm (95.5%) and post-operative complications (88.9%) did not reveal any clinical manifestations. Although all of the patients with obstetric disorders had bleeding, only 20.0% of the patients had organ failure. In contrast, although only 15.4% of the patients with infections had bleeding, 76.9% of these patients had organ failure. Bleeding was observed in 31.9-50.0% of DIC patients with liver disease, hematologic malignancies, and solid tumors. Organ failure was observed in 21.7-33.3% of DIC patients with liver disease, hematological malignancies, and solid tumors. Analysis by measurement of plasma levels of antiplasmin and plasmin-antiplasmin complex suggested that excessive fibrinolysis might contribute to the development of bleeding in these DIC patients. Differences in plasma levels of thrombin-antithrombin complex and cross-linked fibrin degradation products could not account for the differences in the incidence of organ failure in the patients. These findings suggest that the clinical manifestation of DIC varies and might not only be a reflection of microthrombus formation but also a reflection of the other underlying pathomechanisms.

Systemic activation of tissue-factor dependent coagulation pathway in evolving acute respiratory distress syndrome in patients with trauma and sepsis.

Extravascular coagulation and fibrin deposition coupled with perturbations of intravascular coagulation occurs in association with acute respiratory distress syndrome (ARDS). To evaluate the pathogenetic role of an extrinsic coagulation pathway in the intravascular coagulation of ARDS patients and to explore the time course of the changes of tissue factor levels, platelet counts, and disseminated intravascular coagulation (DIC), we performed a prospective cohort study. The study subjects consisted of 113 patients: 27 patients with ARDS, 31 patients at risk for but not developing the syndrome, and 55 patients without ARDS. According to the underlying disease, the patients were further subdivided into two groups: patients with trauma (n = 76) and patients with sepsis (n = 37). Ten normal healthy volunteers served as control subjects. Plasma tissue factor antigen (tissue factor) levels and platelet counts were measured on the day of admission and on days 1 through 4 after admission. Simultaneously, the DIC scores were determined. The values of tissue factor in the patients with ARDS were significantly more elevated than those measured in the other two groups (p < 0.001) and control subjects (p < 0.001) on the day of admission. The values continued to be markedly high up to day 4 of admission. On the day of admission, the platelet counts in the ARDS patients showed significantly lower values (p < 0.05) than those in the other two groups. The incidence of DIC and the DIC scores in ARDS patients were significantly higher than those in the other two groups. The tissue factor levels (r(s) = 0.428, p < 0.0001) and DIC scores (r(s) = 0.357, p < 0.0002) correlated significantly with Lung Injury Score. When the patients were subdivided into two subgroups, i.e., trauma and sepsis, some differences of the tissue factor levels were noted between the two groups. We demonstrated that tissue-factor dependent coagulation pathway of plasma is extensively activated in patients with ARDS, followed by intravascular coagulation and platelet consumption. We further provide precise information on the time course of tissue factor levels and DIC in patients with ARDS and those at risk for developing this syndrome.

Disseminated intravascular coagulation and sustained systemic inflammatory response syndrome predict organ dysfunctions after trauma: application of clinical decision analysis.

To determine the accuracy of disseminated intravascular coagulation (DIC) and sustained systemic inflammatory response syndrome (SIRS) in predicting posttrauma multiple organ dysfunction syndrome (MODS) and to find a simple laboratory test for detecting MODS. In trauma patients, the duration of SIRS is the main determinant for MODS and outcome. One hundred thirty-six patients with trauma were classified into subgroups according to the duration of SIRS: patients without SIRS (n = 27), patients with SIRS for <2 days (n = 52), and patients with SIRS for > or =3 days (n = 57). Platelets and five coagulation and fibrinolytic laboratory tests for diagnosing DIC were measured on the day of admission and on days 1 through 4 after admission. Simultaneously, the DIC score was determined. The diagnostic accuracy of DIC and sustained SIRS for the prediction of MODS was determined using likelihood ratios. A receiver operating characteristic curve of platelet counts for predicting MODS was also constructed. Platelet counts showed significant differences among the three groups. The incidence of DIC, acute respiratory distress syndrome, and MODS was significantly higher in patients with SIRS for > or =3 days compared with those in the other groups, and they had a poor outcome. Likelihood ratios of DIC and SIRS for > or =3 days for predicting posttrauma MODS were 11.6 and 6.25, respectively. Platelet counts (80 x 10(9)/l) on day 1 had a sensitivity of 83.3% and a specificity of 100% for predicting MODS. Disseminated intravascular coagulation and sustained SIRS are strong determinants for posttrauma MODS. This retrospective analysis supports the possibility that platelet counts can be used as a simple laboratory test for predicting MODS. This hypothesis requires proof using a prospective clinical survey.

Predictors of fetal mortality in pregnant trauma patients.

Fetal mortality after trauma is significant. This study was aimed at identifying factors responsible for this high fetal mortality. All pregnant trauma patients admitted to the two major Toronto trauma institutions during the period of November of 1991 to February of 1996 with an Injury Severity Score (ISS) > or = 12 were assessed. Data on age, gestation, hypotension, ISS, hemoglobin, blood transfusion, length of stay, disseminated intravascular coagulation (DIC), and specific maternal injury were analyzed retrospectively to determine predictors of fetal mortality by comparison of patients with and without fetal survival. Twenty of a total of 68 pregnant trauma patients qualified for entry into the trauma registry by having an ISS > or = 12. Overall fetal mortality was 65% (13 of 20) for ISS > or = 12, and there was one maternal death (age, 29 years; ISS, 66). There were no statistically significant differences between the fetal death and fetal survival groups in age (29.2 +/- 6.2 vs. 30.4 +/- 3.9 years), gestation (25.3 +/- 10.5 vs. 24.1 +/- 9.2 weeks), lowest systolic blood pressure (98.3 +/- 33.8 vs. 112 +/- 18.0 mm Hg), head injury rate (3 of 13 vs. 1 of 7), extremity injury rate (8 of 13 vs. 2 of 7), abdominal injury rate (4 of 13 vs. 0 of 7), pelvic fracture rate (6 of 13 vs. 1 of 7), and chest injury rate (5 of 13 vs. 3 of 7). However, ISS (27.7 +/- 3.5 vs. 14.2 +/- 11.4), lowest hemoglobin level (78.8 +/- 17.0 vs. 101.9 +/- 17.1), blood transfusions (10.8 +/- 6.3 vs. 0.9 +/- 1.6 units), length of stay (20.9 +/- 16.7 vs. 8.2 +/- 4.9 days), and the incidence of DIC (8 of 13 vs. 0 of 7) were statistically significantly different between the two groups (p < 0.05). All eight patients with abruptio placentae had associated fetal mortality. Apart from ISS, blood loss, and abruptio placentae; the presence of DIC was the most significant predictor of fetal mortality. This finding may represent stimulation of DIC by placental products entering the maternal circulation after significant intrauterine injury.