Intravascular Coagulation In Patients Research Articles

Heparin therapy in sepsis and sepsis-associated disseminated intravascular coagulation: a systematic review and meta-analysis

BackgroundSepsis is a life-threatening condition that affects 49 million people annually. Managing sepsis-associated coagulopathy poses a significant challenge due to its high mortality rates in intensive care. Recent reports suggest that administering heparin may offer potential survival benefits in sepsis and coronavirus disease cases. However, there is currently no established evidence supporting the use of heparin for sepsis. Thus, in this study, we aimed to assess the efficacy of heparin administration in patients with sepsis.MethodsA systematic review was conducted following the PRISMA guidelines. The searches included MEDLINE, Cochrane, and Japanese databases up to January 2023. The inclusion criteria consisted of randomized control trials (RCTs) involving adult sepsis patients receiving heparin. The risk of bias was assessed using RoB2, and the data extraction included 28-day mortality and bleeding complications.ResultsOut of 1733 initial articles, only three studies met the inclusion criteria. The analysis, which included 426 patients, showed no significant difference in 28-day and in-hospital mortality between the heparin and control groups (risk ratio [RR] = 0.86, 95% confidence interval [CI]: 0.60–1.24). Subgroup analysis of sepsis-associated disseminated intravascular coagulation (DIC) patients (n = 109) also did not show a significant reduction in mortality (RR = 0.84, 95% CI: 0.51–1.38). Heterogeneity was zero, and no publication bias was observed. Additionally, there was significant difference in bleeding complications (RR = 0.49, 95% CI: 0.24–0.99, p = 0.047).ConclusionsThis meta-analysis did not demonstrate a survival benefit of heparin administration in patients with sepsis and sepsis-associated DIC. Further investigation into the potential benefits of heparin is warranted. Moreover, the analysis revealed no increase in bleeding risks with heparin administration; instead, a significant reduction in the risk of bleeding was noted.Trial registrationThis review was preregistered with PROSPERO (registration: CRD42023385091).

Risk Factors for Mortality in Critically Ill Patients with Coagulation Abnormalities: A Retrospective Cohort Study.

Coagulation abnormalities are common and prognostically significant in intensive care units (ICUs) and are associated with increased mortality. This study aimed to explore the association between the levels of coagulation markers and the risk of mortality among ICU patients with coagulation abnormalities. This retrospective study investigated patients with coagulation abnormalities in the ICU between January 2021 and December 2022. The initial point for detecting hemostatic biomarkers due to clinical assessment of coagulation abnormalities was designated day 0. Patients were followed up for 28 days, and multivariate logistic regression analysis was utilized to identify risk factors for mortality. Of the 451 patients analyzed, 115 died, and 336 were alive at the end of the 28-day period. Multivariate analysis revealed that elevated thrombin-antithrombin complex (TAT), tissue plasminogen activator inhibitor complex (tPAIC), prolonged prothrombin time, and thrombocytopenia were independent risk factors for mortality. For nonovert disseminated intravascular coagulation (DIC) patients, older age and thrombocytopenia were associated with increased risks of mortality, whereas elevated levels of plasmin α2-plasmin inhibitor complex (PIC) were found to be independent predictors of survival. In patients with overt DIC, elevated levels of tPAIC were independently associated with increased risks of mortality. Nevertheless, thrombocytopenia was independently associated with increased risks of mortality in patients with pre-DIC. Coagulation markers such as the TAT, tPAIC, PIC, and platelet count were significantly associated with mortality, underscoring the importance of maintaining a balance between coagulation and fibrinolysis. These findings highlight the potential for targeted therapeutic interventions based on specific coagulation markers to improve patient outcomes.

Impact of Lactate on Disseminated Intravascular Coagulation in Patients with Severe Trauma

Abstract Introduction: The association between elevated lactate levels and the development of disseminated intravascular coagulation (DIC) in patients with severe trauma remains unclear. Hence, this study aimed to explore the association between lactate and the development of DIC in patients with severe trauma. Methods: This prospective cohort study was conducted on consecutive patients with severe trauma who were hospitalized in the intensive care unit from January 2020 to January 2023. The primary outcome measured was the occurrence of DIC in patients in the emergency department or posthospitalization. Logistic regression analysis evaluating the risk values for lactate and DIC, the receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) examinations studying the predictive efficiency of lactate for DIC. The Kaplan–Meier survival curve was used to assess patient survival. Sensitivity robustness analysis included modified Poisson regression, E-value, subgroup analysis, and numerical variable transformation analysis. Results: Logistic regression analysis corrected for confounding factors showed that lactate was a risk factor for DIC in patients with severe trauma (adjusted odds ratio [OR]: 1.374, 95% confidence interval [CI]: 1.206–1.566). Lactate predicted DIC risk with a 0.8513 area under the ROC curve (95% CI: 0.7827–0.9199), 4.8 cutoff value, 0.8333 sensitivity, and 0.8014 specificity. DCA showed the correlation between lactate and DIC. The mortality rate of patients with a high risk of DIC was significantly higher than that of patients with a low risk (log-rank test, P < 0.001). The modified Poisson regression showed that lactate was a risk factor for DIC (risk ratio: 1.188, 95% CI: 1.140–1.237). E-value was 1.645, and the lower limit of 95% CI was 1.495. The logistic regression analysis after subgroup analysis and transformation of numerical variables showed that lactate remained a risk factor for DIC. Conclusions: Elevated lactate is closely associated with the occurrence of DIC in patients with severe trauma. Lactate seems to be a good predictive factor for DIC manifestation in patients with severe trauma.

Microparticle-associated tissue factor activity correlates with the inflammatory response in septic disseminated intravascular coagulation patients.

Sepsis is often accompanied by the formation of disseminated intravascular coagulation (DIC). Microparticles can exert their procoagulant and proinflammatory properties in a variety of ways. The purpose of this study was to investigate the relationship between microparticle-associated tissue factor activity (TF+-MP activity) and the inflammatory response. Data from a total of 31 DIC patients with sepsis and 31 non-DIC patients with sepsis admitted to the ICU of the First Affiliated Hospital of Harbin Medical University from December 2017 to March 2019 were collected. Blood samples were collected and DIC scores were calculated on the day of enrollment. The hospital's clinical laboratory completed routine blood, procalcitonin, and C-reactive protein tests. TF+-MP activity was measured using a tissue factor-dependent FXa generation assay. Interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) levels were determined using ELISA kits. Compared with the non-DIC group, the DIC group had higher levels of leukocytes, neutrophils, procalcitonin, C-reactive protein, IL-1β, and TNF-α, and more severe inflammatory reactions. TF+-MP activity in the DIC group was higher than that in the non-DIC group. In sepsis patients, TF+-MP activity was strongly correlated with inflammatory response indices and DIC scores. TF+-MP activity may play a major role in promoting inflammatory response in septic DIC.

HMG-CoA reductase inhibitors and the attenuation of risk for disseminated intravascular coagulation in patients with sepsis.

Disseminated Intravascular Coagulation (DIC) is a syndrome of dysregulated coagulation. Patients with sepsis are at increased risk for DIC. HMG-CoA Reductase Inhibitors (Statins) are primarily used as lipid-lowering agents; however, studies have suggested statins may possess anti-inflammatory, antithrombotic, anticoagulant, and endothelial stabilizing properties. These mechanisms may oppose those that underlie the pathogenesis of septic DIC. To evaluate whether statins may be protective against the development of DIC, we conducted a multi-center, retrospective case-control study where 86,638 critically ill patients admitted to the ICU with sepsis, severe sepsis or septic shock were identified during a 3-year period. Patients who developed DIC during their hospitalization were identified and stratified by whether they received a statin or not during their hospitalization. Odds ratios for development of DIC was calculated by composite of any statin, as well as low, moderate, and high intensity statins. 2236 patients would develop DIC compared to 84,402 who did not. The use of any statin was associated with a reduced likelihood for developing DIC (odds ratio [OR], 0.69; 95% CI, 0.61-0.78). This was observed with use of both moderate (OR, 0.64; 95% CI, 0.53-0.77) and high (OR, 0.72; 95% CI, 0.61-0.84) but not low intensity statins (OR, 0.84; 95% CI, 0.53-1.32). The use of moderate and high intensity statins was associated with a significantly reduced odds of developing DIC in critically ill patients with sepsis. This present study may be the first to suggest that statin medications may independently reduce the frequency of DIC in critically ill patients with severe sepsis or septic shock. More research is needed to investigate the potential for this class of medication to be protective against DIC.

Establishment and validation of a risk prediction model for disseminated intravascular coagulation patients with electrical burns

Establishment and validation of a risk prediction model for disseminated intravascular coagulation patients with electrical burns

Diagnosis of Disseminated Intravascular Coagulation in Patients Suffering from Sepsis using the Modified International Society of Thrombosis and Haemostasis Criteria and Japanese Association of Acute Medicine Criteria

Introduction: The international task force defines sepsis as ‘life- threatening organ dysfunction caused by a dysregulated host response to infection’. Disseminated Intravascular Coagulation (DIC) is a coagulopathy syndrome that causes microvascular and macrovascular thrombosis and increases the risk of bleeding due to consumptive coagulopathy. Sepsis causes dysfunction in coagulation due to release of inflammatory markers which leads to inappropriate deposition of intravascular fibrin. In order to facilitate the diagnostic process for detecting DIC, the scoring system recommended by International Society of Thrombosis and Haemostasis (ISTH) and Japanese Association of Acute Medicine (JAAM) were used which are based on the global coagulation tests such as the platelet count, Prothrombin time, International Normalised Ratio (INR) and Fibrin Degradation Products (FDPs)/D-dimer. Aim: To determine the prevalence and outcome of DIC in patients suffering from sepsis using ISTH criteria and JAAM criteria. Materials and Methods: A prospective cohort was carried out from January 2021 to July 2022 in the haematology section of pathology department of Government Medical College and Hospital, Aurangabad, Maharashtra, India. Hundred patients suffering from clinically suspected sepsis were included in the study. Venous blood was collected from patients in Ethylene Diamine Tetra-acetic Acid (EDTA) and Citrate bulbs. The tests performed were Complete Blood Count (CBC), Prothrombin Time (PT), INR and D-Dimer. CBC was performed on Fully automated three part cell counter. PT, INR, D-Dimer testing was done on fully automated coagulometer. The above test results were used to diagnose DIC in patients suffering from sepsis using the modified ISTH and JAAM criterias. The results were analysed using Microsoft excel 2019 i.e., chi-square test was applied for p-value calculation. Results: Out of 100 patients with clinically suspected sepsis 35 patients (35%) suffered from Overt DIC using ISTH criteria and 58 patients (58%) suffered from DIC using JAAM criteria. The total mortality in patients with sepsis in the present study was 40%. The mortality in patients with DIC in sepsis using the ISTH criteria was 26 patients (74.28%) and 37 patients (63.79%) using the JAAM criteria. Conclusion: Coagulation abnormalities are widely prevalent in patients with sepsis and are likely to play a key role in multi- organ dysfunction. Both ISTH and JAAM criteria are good predictors of mortality.

Emergent Large-Bore Central Venous Catheter Placement in Severely Thrombocytopenic Patients with Suspected Immune-Mediated Thrombotic Thrombocytopenic Purpura Is Safe and Effective

Introduction: Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a progressive and nearly uniformly fatal disease if not suspected and managed with plasma exchange (PLEX). Initiation of PLEX requires placement of a large-bore central venous catheter (CVC) in a patient with severe thrombocytopenia where platelet transfusion is contraindicated except in the setting of life-threatening hemorrhage. We sought to determine the safety and complication rates of large-bore CVC placement in patients with suspected iTTP. Methods: The Parkland Health and Hospital System electronic medical record system was queried for ADAMTS13 labs from 7/2011 to 7/2021, identifying 1,371 ordered tests with 465 being ordered in the emergency department, observation, or inpatient setting. Sixty-eight patients had a large-bore CVC placed for PLEX with suspicion for iTTP. Characteristics of providers performing CVC placement were obtained via chart review. Records were reviewed for complications, including death, infection, thrombosis, bleeding, pneumothorax, or pressure ulcers. Minor bleeding complications were procedure site hematomas and self-limited episodes of bleeding requiring manual pressure. The only major complication was a hematoma that required intubation for airway protection. Categorical variables were compared using the chi-square test, while continuous variables were compared using the Wilcox rank sum test. Results: Of the 68 patients, the majority were Black or Hispanic (84%). Central venous catheter placement was most often performed by General Surgery (68%) followed by the Medical Intensive Care Unit (MICU; 12%), Emergency Medicine (7%), and Nephrology (7%). Surgery and Emergency Medicine placed significantly more catheters in patients who ultimately had iTTP (P = 0.03). Resident physicians placed the majority of CVCs (79%) with no prophylactic blood products used in over 90% of cases. There was a 12% (8 out of 68) complication rate predominantly related to bleeding (n=7), although one patient had a pressure ulcer due to a lack of mobility after a femoral vein CVC placement. There was only one severe complication with the development of a rapidly expanding hematoma during an internal jugular (IJ) line placement causing airway compromise and requiring intubation. There were no differences in complication rates between line placement by General Surgery versus other services (P = 0.91) or with prophylactic platelet (P = 0.81), cryoprecipitate (P = 0.59), or FFP (P = 0.70) transfusions. A significant association was observed between the number of line attempts (median [IQR]) and complications (2 [2-4] v patients without complications: 1 [1-1], P < 0.001). In patients with iTTP, pre-procedural coagulation parameters had significantly lower platelets, lower INR, lower PT, and higher fibrinogen, suggesting a level of coagulopathy and/or disseminated intravascular coagulation in patients who were ultimately not found to have iTTP. Discussion: In a tertiary hospital, there was only one severe complication of large-bore CVC placement was observed in a cohort of 68 patients-most of whom had severe thrombocytopenia and did not receive prophylactic platelet or cryoprecipitate transfusions. Furthermore, resident physicians placed 79% of these CVCs without a significant increase in complication rate. Given that iTTP is a severe and progressive disease requiring emergent intervention, our findings suggest that CVC insertion for PLEX should not be delayed due to concerns regarding thrombocytopenia or bleeding complications. Most complications were minor bleeding or hematomas that resolved with pressure and observation. No significant difference in the rate of complications was observed when comparing surgical and non-surgical services. Conversely, there was an association between the number of CVC placement attempts and complications, suggesting that the line should be placed by whomever is qualified and available to expedite treatment. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

HMG-CoA Reductase Inhibitors and the Modification of Risk for Disseminated Intravascular Coagulation in Patients with Sepsis

Background: Disseminated intravascular coagulation (DIC) is a highly morbid syndrome characterized by uncontrolled activation of coagulation leading to the consumption of clotting factors and platelets and increasing risk for life-threatening hemorrhage. Sepsis is one of the underlying disorders that can provoke DIC. The mechanism of DIC is thought to involve tissue factor overexpression, defective anticoagulation pathways, endothelial and monocytic cytokines, oxidation, and calpains. HMG-CoA reductase inhibitors (statins) have demonstrated anti-inflammatory and mild anti-coagulant properties effecting the pathways proposed to mediate DIC. Objectives: The aim of this study is to evaluate whether septic patients who take statin medications are at reduced risk for the development of DIC. Methods: In a retrospective cohort study, 120,397 critically ill patients with sepsis with and without shock were identified within a three year period from 2019 to 2021. Patients were stratified by whether they were medicated with low, medium, high intensity statins or none. Odds ratios for the development of DIC were calculated. Results: Overall, 2795 patients would develop DIC. The odds ratio for the development of DIC were .700 (95% CI .617-.794), .615 (95% CI .529-.714), and .901 (95% CI .635-1.277) when comparing high, moderate, and low intensity statin therapy to no statin therapy. Conclusion: The use of moderate and high intensity statins correlated with a significantly reduced association between critically ill septic patients and the development of DIC. More research is needed to clarify the potential for this class of medication to be protective against DIC. This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Thromboelastography maximum amplitude as an early predictor of disseminated intravascular coagulation in patients with heatstroke

Objectives The aim of this study was to investigate the ability of TEG to predict DIC associated with heatstroke. Methods We carried out a retrospective, single-center study of 67 patients with heatstroke admitted to an intensive care unit (ICU) at a comprehensive hospital between July 2016 and August 2021. Conventional coagulation tests (CCTs) and TEG were performed within 2 h of admission in ICU. Patients were diagnosed with DIC based on International Society of Thrombosis and Hemostasis criteria, and those with or without DIC were compared in terms of CCTs and TEG findings. The ability of individual parameters to predict DIC was assessed based on logistic regression and the area under receiver operating characteristic curves (AUC). Results Of the 67 patients, 19 (28.4%) were diagnosed with DIC. Compared to patients without DIC, those with DIC had significantly longer reaction time [14.5(10.6–26.0) vs. 6.2(5.1–10.1)min](p < 0.001) and kinetic time [10.9(5.9–25.0) vs. 2.7(2.2–4.7) min](p < 0.001). Conversely, those with DIC had significantly lower alpha angle [22(9.1–43.3) vs. 55.0(44.8–61.7)°](p < 0.001), maximum amplitude (MA) [(26.9(17.7–41.4) vs. 52.2(45.8–58.1) mm)] (p < 0.001) and coagulation index [-17.3(-39 to −7.9）vs. −2.4(-6.2to-0.6)](p < 0.001). MA at a cutoff value of 45.4 mm gave an AUC of 0.9 for predicting DIC, with sensitivity of 77.1%, specificity of 89.5%, positive predictive value of 10.5% and negative predictive value of 22.9%. Multifactorial logistic regression identified MA < 45.4 mm as an independent predictor of DIC (odds ratio 9, 95% confidence interval 1.2-69.2, p = 0.035). MA decreased significantly as DIC score increased and was significantly lower in the non-survivors on admission. Conclusions MA < 45.4 mm in patients with heatstroke may predict elevated risk of DIC. Highlights Patients with heatstroke-induced disseminated intravascular coagulation (DIC) has high mortality. A retrospective, single-center study was performed to investigate the ability of thromboelastography (TEG) to predict DIC associated with heatstroke. The maximum amplitude (MA) value of TEG decreased significantly with the increase of DIC score. MA < 45.4 mm was firstly demonstrated to an independent predictor of heatstroke-induced DIC.

A Suggested Link Between Antithrombin Dose and Rate of Recovery from Disseminated Intravascular Coagulation in Patients with Severe Organ Failure.

IntroductionThe efficacy of antithrombin (AT) supplementation against septic disseminated intravascular coagulation (DIC) may depend on various pre-existing factors, particularly the AT dose and multiple organ dysfunction severity. This study aimed to identify the impactful factors for early DIC recovery.MethodsPatients’ clinical records, including AT therapy and septic DIC data, were retrospectively extracted from January 2015 to December 2020. The patients were divided into those with early DIC recovery (n = 34) and those without (n = 37). Multivariate logistic regression analysis determined significant independent factors. Time-to-event analysis confirmed how these factors affected the DIC recovery time.ResultsThe AT dose per patient body weight (odds ratio [95% confidence interval]: 2.879 [1.031-8.042], P = 0.044) and pre-existing organ dysfunction severity (0.333 [0.120-0.920], P = 0.034) were significant independent factors affecting early DIC recovery. A higher AT dose significantly shortened the DIC recovery time among patients with severe organ dysfunction (P < 0.01), but not among non-severe patients (P = 0.855).ConclusionThe therapeutic efficacy of AT treatment for septic DIC might depend on the severity of pre-existing organ failure and the AT dose per patient body weight.

Urinary thrombin as a marker of local disseminated intravascular coagulation in patients with chronic kidney disease

The aim of this research was to study the diagnostic markers of nonovert local disseminated intravascular coagulation (DIC) syndrome in the urine of patients with chronic kidney disease (CKD). We conducted a prospective study involving 140 patients with CKD, of these patients, 100 patients (71.4%; 95% CI 53.4-76.7) had glomerulonephritis (GN) and 40 patients (28.6%; 95% CI 21.3-36.8) had diabetic nephropathy (DN). We diagnosed overt DIC syndrome on the International Society of Thrombosis and Haemostasis (ISTH) scale (&gt;5 points) in 18.6 % of patients. We determined the level of thrombin in the urine of patients who had &lt;5 points on ISTH scale for the diagnosis of local nonovert DIC syndrome in the kidneys. In the urine of healthy individuals, the level of thrombin did not exceed 1 ng/ml, so we found no thrombinuria at a thrombin level &lt;1 ng/ml. In 56.1% of patients, we found urinary thrombin levels &gt;1 ng/ml. The average level of thrombin in the urine of these patients was 6.5 (4.8; 10.6) ng/ml. In our opinion, the presence of thrombinuria indicates the intensity of monocytic-macrophage inflammation in the glomeruli and may be a criterion for nonovert, local DIC syndrome in the kidneys. The association of overt DIC syndrome with decreased blood albumin, reduced glomerular filtration rate (GFR), increased daily protein excretion (DPE) indicates its occurrence in severe underlying disease, in the presence of nephrotic syndrome and in the severe stages of CKD. Early diagnosis of nonovert local DIC syndrome would be more useful, since the process is still reversible and controlled, and timely use of antiplatelet and anticoagulant therapy would affect the course and the progression of CKD.

Application of the International Society on Thrombosis and Haemostasis Scoring System in Evaluation of Disseminated Intravascular Coagulation in Patients with Acute Leukemias.

Background Coagulation abnormalities are common in acute leukemia (AL) and disseminated intravascular coagulation (DIC) frequently complicates the onset of AL. Aim To determine the prevalence of overt DIC in AL using the International Society on Thrombosis and Haemostasis (ISTH) scoring system. Materials and Methods This prospective observational study was performed on 57 newly diagnosed or relapsed cases of AL. Detailed clinical history and coagulation profile of the patients were evaluated. Diagnosis of overt and nonovert DIC was established using the ISTH scoring system and results tabulated. Observations A total of 57 patients with AL participated in the study, including 31 (54.39%) patients with acute lymphoblastic leukemia (ALL) and 26 (45.61%) with acute myeloid leukemia (AML). In total, 18 of 57 patients (31.58%) with AL fulfilled the criteria of overt DIC according to the ISTH scoring system, including 10 (32.25%) patients with ALL and 8 (30.76%) patients with AML. The highest prevalence of DIC was seen in the M3 subtype among AML and the L1 subtype among ALL, respectively. The mean ISTH score in patients of overt DIC in ALL and AML patients was 5.1 and 5, respectively. Abnormalities in platelet count and D-dimer levels were the most useful parameters in diagnosing overt DIC and the difference between overt DIC and nonovert DIC groups was highly significant. Conclusions Overt DIC was observed in approximately one-third of patients with AL. Prevalence of overt DIC was found to be comparable in patients with ALL and AML. Mean platelet count and D-dimer levels were the most useful parameters in detecting overt DIC.

Clinical Treatment of Perioperative Disseminated Intravascular Coagulation in Patients Who Underwent Gastrointestinal and Hepato-Biliary-Pancreatic Surgery.

It is unclear how effective recombinant thrombomodulin (rTM) treatment is in disseminated intravascular coagulation (DIC) during the perioperative period of gastrointestinal and hepato-biliary-pancreatic surgery. The current study aimed to evaluate the therapeutic outcomes of rTM for perioperative DIC. We enrolled 100 consecutive patients diagnosed with perioperative DIC after gastrointestinal surgery, and hepato-biliary-pancreatic including emergency procedures, between January 2012 and May 2021. Patients received routine rTM treatment immediately after DIC diagnosis. Then, the DIC, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were calculated and used for evaluation. The outcomes of rTM treatment and the predictors of survival were evaluated. The causative diseases of DIC were as follows: perforated peritonitis, n = 38; intestinal ischemia, n = 23; intra-abdominal abscess, n = 13; anastomotic leakage, n = 7; pneumonia, n = 7; cholangitis, n = 4; and others, n = 6. The 30-day mortality rate was 18.0%. There were significant differences in the platelet count (13.78 vs 10.41, P = .032) and the SOFA score (5.22 vs 9.89, P<.0001) at the start of DIC treatment between the survivor and non-survivor groups (day 0). The survivor group had a significantly lower DIC score (3.13 vs 4.93, P = .0006) and SOFA score (4.94 vs 12.14, P < .0001) and a higher platelet count (13.50 vs 4.34, P < .0001) than the non-survivor group on day 3. Comprehensive and systemic treatment is fundamentally essential for DIC, in which rTM may play an important role in the treatment of perioperative DIC.

Relationship Between Red Blood Cell Distribution Width and All-Cause Mortality in Disseminated Intravascular Coagulation Patients: A Retrospective Analysis.

PurposeStudies regarding death risk factors of disseminated intravascular coagulation (DIC) patients were limited. We conducted this study to investigate whether red blood cell distribution width (RDW) was independently related to all-cause mortality of DIC patients.MethodsWe used data from the Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III v1.4). A total of 2098 patients with DIC were included. The main outcome was in-hospital all-cause mortality.ResultsAfter adjusting for potential covariates, the in-hospital all-cause mortality was positively correlated with RDW. The hazard ratio (HR), 95% confidence intervals (CI), and P-value were 1.08, (1.05, 1.12), and P<0.0001, respectively. The Kaplan–Meier curve found DIC patients with elevated RDW had a lower survival rate than patients with normal RDW (P<0.0001). A nonlinear relationship between RDW and mortality was found with the inflection point 19.2%. When RDW <19.2%, RDW was positively correlated with in-hospital all-cause mortality of DIC patients (HR (95% CI): 1.17 (1.11, 1.24), P<0.0001). An elevation in RDW greater than 19.2% did not result in an additional increased risk of mortality (HR=0.97, 95% CI: 0.91–1.04, P=0.4617).ConclusionRDW is an independent predictor of all-cause mortality in DIC patients. Furthermore, there is a nonlinear association between RDW and all-cause mortality of DIC patients.

Dielectric Blood Coagulometry for the Early Detection of Sepsis-Induced Disseminated Intravascular Coagulation: A Prospective Observational Study.

To evaluate the utility of dielectric blood coagulometry for early sepsis-induced disseminated intravascular coagulation diagnosis. Single-center, prospective observational study. Patients with sepsis or septic shock at the Tokyo Medical and Dental University Hospital of Medicine between September 2019 and September 2020. The patients were divided into three groups according to the timing of disseminated intravascular coagulation diagnosis based on the Disseminated Intravascular Coagulation score by the Japanese Association for Acute Medicine: 1) no disseminated intravascular coagulation group, 2) late-diagnosed disseminated intravascular coagulation group: not diagnosed with disseminated intravascular coagulation on day 1 but diagnosed within 48 hours after admission, and 3) disseminated intravascular coagulation group: diagnosed with disseminated intravascular coagulation on day 1. The study evaluated 80 patients (no disseminated intravascular coagulation, 31 [38.8%]; late-diagnosed disseminated intravascular coagulation, 34 (42.5%); disseminated intravascular coagulation, 15 [18.8%]). We compared the clinical severity scores and mortality of the groups and assessed the correlation between the dielectric blood coagulometry-derived coagulation marker, thrombin levels, and Disseminated Intravascular Coagulation score using Spearman rank correlation. The mortality rate was 0% (0/31) in the no disseminated intravascular coagulation group, 35.3% (12/34) in the late-diagnosed disseminated intravascular coagulation group, and 33.3% (5/15) in the disseminated intravascular coagulation group. Although the Disseminated Intravascular Coagulation score on day 1 did not reflect disseminated intravascular coagulation in approximately 70% of patients who developed disseminated intravascular coagulation by day 2, dielectric clot strength measured by dielectric blood coagulometry on day 1 strongly correlated with disseminated intravascular coagulation development by day 2 (Spearman ρ = 0.824; p < 0.05) and with thrombin level on day 1 (Spearman ρ = 0.844; p < 0.05). Dielectric blood coagulometry can be used to detect early-phase disseminated intravascular coagulation in patients with sepsis and is strongly correlated with thrombin levels. Larger studies are needed to verify our results for developing clinical applications.

The Association Between Serum Anion Gap and All-Cause Mortality in Disseminated Intravascular Coagulation Patients: A Retrospective Analysis.

PurposeStudies regarding death risk factors of disseminated intravascular coagulation (DIC) patients were limited. Therefore, we conducted this study to investigate whether the serum anion gap (AG) was independently related to all-cause mortality of DIC patients.MethodsWe used the data from Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III v1.4). A total of 2,654 DIC patients were included. The main outcomes were in-hospital, 30-day, and 90-day all-cause mortality. The AG was measured upon ICU admission and its association with mortality was evaluated using the Cox proportional-hazards regression model. The generalized additive model and the smooth curve fitting were introduced to examine the non-linear association.ResultsAfter adjusting for potential covariates, the in-hospital, 30-day, and 90-day all-cause mortality were positively correlated with AG. The hazard ratio (HR), confidence intervals (CI), and P were 1.05 (1.04–1.07) <0.0001, 1.06 (1.04–1.07) <0.0001, and 1.05 (1.03–1.07) <0.0001, respectively. We did not find an obvious non-linear relationship between AG and in-hospital, 30-day, and 90-day mortality, which indicated that the association between AG and all-cause mortality of DIC patients was nearly linear.ConclusionSerum AG is positively related with all-cause mortality in DIC patients.

Pitfalls in the assessment of disseminated intravascular coagulation in patients on dabigatran

Dabigatran is an orally administrated anticoagulant that directly inhibits thrombin. However, the drug can affect routine coagulation tests such as prothrombin time (PT), activated partial thromboplastin time (APTT) and thrombin time (TT), as well as haemostasis assays, (e.g., clot-based coagulation factor assays). There are limited data on the effect of dabigatran on some fibrinogen measurements and on D-dimer assays, both important components in the laboratory assessment of disseminated intravascular coagulation (DIC). The objectives of this study were: (1) to determine the effects of various concentrations of dabigatran on fibrinogen and D-Dimer assays; and (2) to compare the von Clauss method of fibrinogen measurement using two reagents with differing thrombin concentrations (35 UNIH/mL and 100 UNIH/mL) and PT-derived fibrinogen measurement in the presence of the drug. Aliquots of pooled normal plasma were spiked with different concentrations of dabigatran to reflect invivo on-therapy levels as well as levels observed in cases of massive accumulation of the drug. Of the routine coagulation assays, in ascending order of sensitivity to dabigatran were PT, APTT and TT. The von Clauss method of measuring fibrinogen using a reagent with low thrombin concentration was affected even at drug levels corresponding to invivo trough concentrations, whereas the reagent with higher thrombin concentration was only affected at drug levels that were above observed peak concentrations in patients taking 150 mg of the drug twice daily. PT-derived fibrinogen was affected at approximately invivo peak drug concentrations. The D-dimer assay was affected only at drug concentrations well above peak drug levels. Attempts at invitro neutralisation of the drug with DOAC-Stop resulted in 'correction' of some of these measurements depending on drug concentration. Like the routine coagulation assays, there is a dabigatran concentration dependent effect on the accuracy of fibrinogen and D-dimer assays. Falsely low fibrinogen results due to dabigatran may confound the assessment of DIC and diagnostic laboratories need to evaluate the performance of their own reagents.

Коагулопатия при инфекции COVID-19.

Введение. Известно о коагулопатиях при инфекциях коронавирусами SARS и MERS. Цель исследования: изучить накопленную информацию о коагулопатии при инфекции COVID-19. Материалы и методы. В библиотеке PubMed провели поиск по ключевым словам «COVID-19», «coagulopathy». Обнаружили 15 публикаций, содержащих результаты оригинальных исследований. Результаты. При тяжелом течении заболевания наблюдают цитокиновый шторм, более высокие уровни Д-димера и продуктов деградации фибрина (ПДФ), более длительное протромбиновое время и активированное частичное тромбопластиновое время. Данные о частоте развития синдрома диссеминированного внутрисосудистого свертывания противоречивы. Заключение. У пациентов с COVID-19 с острой дыхательной недостаточностью наблюдается выраженная гиперкоагуляция. Всем госпитализированным пациентам с COVID-19 рекомендована фармакологическая тромбопрофилактика низкомолекулярными гепаринами или фондапаринуксом. Донорскую плазму для пассивной иммунотерапии нужно переливать только в рамках клинических исследований. Background. Coagulopathies are known for infections with SARS and MERS coronaviruses. Objectives: the reviewing the early accumulated information on coagulopathy in COVID-19. Patients / Methods. In PubMed Library with the keywords «COVID-19», «coagulopathy» we selected 15 publications containing the results of original studies. Results. In severe cases of the disease, a cytokine storm is observed, higher levels of D-dimer and fibrin degradation products (FDP), longer prothrombin time and activated partial thromboplastin time. Data about incidence of disseminated intravascular coagulation are contradictory. Conclusions. Patients with COVID-19 with acute respiratory failure exhibit severe hypercoagulation. Pharmacological thromboprophylaxis with low molecular weight heparins or fondaparinux is recommended for all hospitalized patients with COVID-19. Donor plasma for passive immunotherapy should be transfused only as part of clinical trials.

The effect of recombinant human soluble thrombomodulin on renal function and mortality in septic disseminated intravascular coagulation patients with acute kidney injury: a retrospective study

BackgroundClinical evidence showing the effectiveness of recombinant human soluble thrombomodulin (rhTM) for treating sepsis-induced disseminated intravascular coagulation (DIC) and organ dysfunction (particularly renal injury) is limited because of differences in the inclusion criteria and disease severity among patients. This study aimed to assess the association between rhTM and outcomes in septic DIC patients with acute kidney injury (AKI).MethodsThis retrospective observational study analyzed the data of patients who were admitted to the intensive care unit (ICU) of a single center between January 2012 and December 2018, and diagnosed with sepsis-induced DIC and AKI. Data were extracted as follows: patients’ characteristics; DIC score, as calculated by the Japanese Association for Acute Medicine and the International Society of Thrombosis and Hemostasis criteria; serum creatinine levels; and ICU and 28-day mortality rates. The primary outcome was the dependence on renal replacement therapy (RRT) at ICU discharge. The propensity score (PS) was calculated using the following variables: age, sex, septic shock at admission, DIC score, and KDIGO classification. Subsequently, logistic regression analysis was performed using the PS to evaluate the outcome.ResultsIn total, 97 patients were included in this study. Of these, 52 (53.6%) patients had received rhTM. The dependence on RRT at ICU discharge was significantly lower in the rhTM than in the non-rhTM group (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.19–0.97; P = 0.043). The serum creatinine levels at ICU discharge (OR, 0.31; 95% CI, 0.13–0.72; P = 0.007) and hospital discharge (OR, 0.25; 95% CI, 0.11–0.60; P = 0.002, respectively), and the 28-day mortality rate (OR, 0.40; 95% CI, 0.17–0.93; P = 0.033) were significantly lower in the rhTM than in the non-rhTM group. Moreover, the Kaplan–Meier survival curve revealed significantly lower mortality rates in the rhTM than in the non-rhTM group (P = 0.009). No significant differences in the DIC score and AKI severity were observed between the groups.ConclusionsAmong sepsis-induced DIC patients with AKI, rhTM administration was associated with lower dependence on RRT at ICU discharge, improvement in renal function, and lower 28-day mortality rate.