New criteria for sepsis-induced coagulopathy (SIC) following the revised sepsis definition: a retrospective analysis of a nationwide survey

Deep Vein Thrombosis and Pulmonary Embolism: Two Complications of COVID-19 Pneumonia?

Coronavirus disease 19 (COVID-19) is a worldwide infection which was recently declared a global health emergency by the WHO Emergency Committee. The most common symptoms are fever and cough, which can progress to pneumonia, acute respiratory distress syndrome (ARDS) and/or end-organ failure. Risk factors associated with ARDS and death are older age, comorbidities (e.g., hypertension, diabetes, hyperlipidaemia), neutrophilia, and organ and coagulation dysfunction. Disseminated intravascular coagulation and coagulopathy can contribute to death. Anticoagulant treatment is associated with decreased mortality in severe COVID-19 pneumonia. In this report we describe two patients with COVID-19 pneumonia who developed venous thromboembolism.

Effect of therapeutic plasma exchange on endothelial activation and coagulation-related parameters in septic shock

Background

A dysbalanced coagulation system is part of the pathological host response to infection in sepsis. Activation of pro-coagulant pathways and attenuation of anti-coagulant activity ultimately lead to microvascular stasis and consequent organ failure. No treatment approaches specifically targeting this axis are available. We explored the effects of therapeutic plasma exchange (TPE) on microvascular coagulation dysbalance in septic shock.

Methods

We conducted a prospective single-center study enrolling 31 patients with early septic shock (onset < 12 h) requiring high doses of norepinephrine (NE > 0.4 μg/kg/min). Clinical and biochemical data, including measurement of protein C; a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS13); and von Willebrand factor antigen (vWF:Ag), were obtained before and after TPE against fresh frozen plasma.

Results

Antithrombotic acting proteins such as antithrombin-III (ATIII) and protein C were markedly reduced in septic patients, but their activity increased after TPE (ATIII, 51% (41–61) vs. 63% (48–70), p = 0.029; protein C, 47% (38–60) vs. 62% (54–69), p = 0.029). Median ADAMTS13 activity was increased by TPE from 27 (21–42) % before to 47 (38–62) % after TPE (p < 0.001). In contrast, vWF:Ag was elevated and could be reduced by TPE (353 (206–492) IU/dL vs. 170 (117–232) IU/dL, p < 0.001). Regression analysis yielded a correlation between ADAMTS13 activity and platelet count (p = 0.001, R² = 0.316).

Conclusions

Septic shock was associated with activation of pro-coagulant pathways and simultaneous depletion of anti-coagulant factors. TPE partially attenuated this dysbalance by removing pro- and by replacing anti-coagulant factors.

Trial registration

ClinicalTrials.gov, NCT03065751. Retrospectively registered on 28 February 2017.

Plasma Hsa-miR-92a-3p in correlation with lipocalin-2 is associated with sepsis-induced coagulopathy

BACKGROUND

Sepsis is a life-threatening situation, and it can be rendered more severe by coagulopathy. We here examine a novel plasma biomarker for sepsis-induced coagulopathy.

METHODS

A total of 116 patients diagnosed with sepsis were recruited and divided into two groups by whether they also had coagulopathy. Plasma samples were collected on arrival at the intensive care unit. Fifteen sepsis-alone and 15 sepsis-induced coagulopathy plasma samples were mixed and sent for microRNA sequencing. Differently expressed microRNAs were then validated by quantitative reverse transcriptase polymerase chain reaction in 52 sepsis-alone and 34 sepsis-induced coagulopathy patients; plasma lipocalin-2 was measured as well.

RESULTS

Four microRNAs were selected from microRNA sequencing. Only hsa-mir-92a-3p was differently expressed in the validation set. Its level of expression was significantly lower in sepsis-induced coagulopathy group. Hsa-mir-92a-3p had an area under a receiver operating characteristic curve of 0.660 (95% confidence interval, 0.537, 0.782). The plasma Hsa-mir-92a-3p level was related to activated partial thromboplastin time, prothrombin activity, and plasma lipocalin-2 level. A binary logistic model showed an association between hsa-mir-92a-3p and fibrinogen with SIC.

CONCLUSIONS

The utility of hsa-mir-92a-3p as a biomarker for sepsis-induced coagulopathy needs more verification, and the regulatory mechanism of hsa-mir-92a-3p in coagulation disorder and its potency as a therapeutic target must be confirmed.

Should we treat sepsis-induced DIC with anticoagulants?

Background

Disseminated intravascular coagulation (DIC) is a common complication in sepsis because of crosstalk between the immune system and the coagulation system. Several anticoagulant agents have been tested in an attempt to improve the survival of patients with sepsis and sepsis-induced DIC. Here, we discuss the rationale against using anticoagulation therapy in septic DIC.

Main body of the abstract

Coagulopathy and DIC are associated with increased mortality in sepsis. Several anticoagulant agents have been tested in an attempt to improve the survival of patients with sepsis and sepsis-induced DIC, but have proven largely ineffective. This is because of two major factors. First, the coagulation system is complex and closely related to the immune system. When we manipulate one of the factors involved in these systems, we may disturb the delicate homeostasis between them. A second factor may be failure to identify patients who will benefit from anticoagulation therapy. This may be attributed partly to the fact that there is no gold standard for the diagnosis of DIC, and there are consequently several diagnostic criteria, none of which are specifically designed for sepsis-induced DIC. Application of precision medicine, of the kind currently being applied in other intensive care fields, may be the key to overcoming these challenges. Until we know the precise target population, we should not use anticoagulation therapy in sepsis-induced DIC outside a research setting.

Short conclusion

There is no strong evidence to support the effectiveness of routine anticoagulation therapy in sepsis-induced DIC, and it should not be used clinically until more is known regarding the population of patients who may benefit from it.

Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II

In a resource-limited country like India, rationing of scarce critical care resources might be required to ensure appropriate delivery of care to the critically ill patients suffering from COVID-19 infection. Most of these patients require critical care support because of respiratory failure or presence of multiorgan dysfunction syndrome. As there is no pharmacological therapy available, respiratory support in the form of supplemental oxygen, noninvasive ventilation, and invasive mechanical ventilation remains mainstay of care in intensive care units. As there is still dearth of direct evidence, most of the data are extrapolated from the experience gained from the management of general critical care patients.

How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020;24(Suppl 5):S254–S262.

A Machine-Learning Approach for Dynamic Prediction of Sepsis-Induced Coagulopathy in Critically Ill Patients With Sepsis

Background: Sepsis-induced coagulopathy (SIC) denotes an increased mortality rate and poorer prognosis in septic patients. Objectives: Our study aimed to develop and validate machine-learning models to dynamically predict the risk of SIC in critically ill patients with sepsis. Methods: Machine-learning models were developed and validated based on two public databases named Medical Information Mart for Intensive Care (MIMIC)-IV and the eICU Collaborative Research Database (eICU-CRD). Dynamic prediction of SIC involved an evaluation of the risk of SIC each day after the diagnosis of sepsis using 15 predictive models. The best model was selected based on its accuracy and area under the receiver operating characteristic curve (AUC), followed by fine-grained hyperparameter adjustment using the Bayesian Optimization Algorithm. A compact model was developed, based on 15 features selected according to their importance and clinical availability. These two models were compared with Logistic Regression and SIC scores in terms of SIC prediction. Results: Of 11,362 patients in MIMIC-IV included in the final cohort, a total of 6,744 (59%) patients developed SIC during sepsis. The model named Categorical Boosting (CatBoost) had the greatest AUC in our study (0.869; 95% CI: 0.850-0.886). Coagulation profile and renal function indicators were the most important features for predicting SIC. A compact model was developed with an AUC of 0.854 (95% CI: 0.832-0.872), while the AUCs of Logistic Regression and SIC scores were 0.746 (95% CI: 0.735-0.755) and 0.709 (95% CI: 0.687-0.733), respectively. A cohort of 35,252 septic patients in eICU-CRD was analyzed. The AUCs of the full and the compact models in the external validation were 0.842 (95% CI: 0.837-0.846) and 0.803 (95% CI: 0.798-0.809), respectively, which were still larger than those of Logistic Regression (0.660; 95% CI: 0.653-0.667) and SIC scores (0.752; 95% CI: 0.747-0.757). Prediction results were illustrated by SHapley Additive exPlanations (SHAP) values, which made our models clinically interpretable. Conclusions: We developed two models which were able to dynamically predict the risk of SIC in septic patients better than conventional Logistic Regression and SIC scores.

Predictors of 30-Day In-Hospital Mortality in Patients Undergoing Urgent Abdominal Surgery Due to Acute Peritonitis Complicated with Sepsis

Background

Sepsis is a life-threatening condition with high morbidity and mortality rate. Identifying early prediction factors of critical situations in intra-abdominal sepsis patients can help reduce mortality rates. This prospective study was carried out to evaluate the association of technically available factors with 30-day in-hospital mortality.

Material/Methods

There were 67 intra-abdominal sepsis patients included in the study; patients were observed for 30 days postoperatively. The data was processed using SPSS24.0 statistical analysis package. All tests that had a significance level of 0.05 were selected.

Results

Septic shock in association with increase in age per year showed increase the odds of mortality and prognosed 30-days in hospital mortality correctly in 79% of cases. The observed OR was 12.24 (P<0.001). Multiple logistic regression model 2 for the 30-day mortality identified a combination of septic shock, age (≥70 years), time from peritonitis symptoms to surgery prognose mortality with accuracy of 82%. The most accurate model to prognose 30-day in-hospital mortality included the presents of septic shock, age, time from peritonitis symptoms to surgery, drop of MAP <65 mmHg) post-induction, the odds of mortality 8.86 (P=0.001). Severe hypotension post-induction was more frequent in patients who were not diagnosed with sepsis (P=0.035).

Conclusions

The present study revealed a simple indicator for the risk for death under diffuse peritonitis patients complicated with sepsis. Septic shock, increase in age per year, peritonitis symptoms lasting more than 30 hours, and severe hypotension post-induction had a negative prognostic value for mortality in patients with intra-abdominal sepsis, and might be a high risk for 30-day mortality.

Diagnosis of sepsis-induced disseminated intravascular coagulation and coagulopathy

Disseminated intravascular coagulation (DIC) is a frequent complication in sepsis. Once patients develop DIC, the mortality rate increases significantly. Moreover, recent studies have suggested that coagulation disorder plays a significant role in the development of organ dysfunction in sepsis. Thus, the early detection of DIC is vital in sepsis care, and the Japanese Association for Acute Medicine established a set of original diagnostic criteria in 2006 (JAAM DIC). Since then, the usefulness of the JAAM DIC has been repeatedly reported, and these criteria have been widely adopted in emergency and critical care settings in Japan. Different criteria have also been released by the International Society on Thrombosis and Haemostasis (ISTH overt-DIC), and the latter criteria are presently considered to be the international standard. Compared with the JAAM DIC, the ISTH overt-DIC criteria are stricter and the timing of diagnosis is later. This discrepancy is because of conceptual differences. As many physicians think sepsis-associated DIC is the target of anticoagulant therapies in Japan, the JAAM DIC criteria were designed to allow the early initiation of treatment. As other countries do not provide DIC-specific treatments, early diagnosis is not necessary, and this situation has led to a significant gap. However, as overt-DIC is a late-phase coagulation disorder, a need for early detection has been advocated, and members of the ISTH have recently proposed the category of sepsis-induced coagulopathy. In this review, we introduce the strengths and weaknesses of the major criteria including JAAM-DIC, ISTH overt-DIC, sepsis-induced coagulopathy, and Japanese Society on Thrombosis and Haemostasis-DIC.

Advance in the Management of Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation

Coagulopathy commonly occurs in sepsis as a critical host response to infection that can progress to disseminated intravascular coagulation (DIC) with an increased mortality. Recent studies have further defined factors responsible for the thromboinflammatory response and intravascular thrombosis, including neutrophil extracellular traps, extracellular vesicles, damage-associated molecular patterns, and endothelial glycocalyx shedding. Diagnosing DIC facilitates sepsis management, and is associated with improved outcomes. Although the International Society on Thrombosis and Haemostasis (ISTH) has proposed criteria for diagnosing overt DIC, these criteria are not suitable for early detection. Accordingly, the ISTH DIC Scientific Standardization Committee has proposed a new category termed "sepsis-induced coagulopathy (SIC)" to facilitate earlier diagnosis of DIC and potentially more rapid interventions in these critically ill patients. Therapy of SIC includes both treatment of the underlying infection and correcting the coagulopathy, with most therapeutic approaches focusing on anticoagulant therapy. Recently, a phase III trial of recombinant thrombomodulin was performed in coagulopathic patients. Although the 28-day mortality was improved by 2.6% (absolute difference), it did not reach statistical significance. However, in patients who met entry criteria for SIC at baseline, the mortality difference was approximately 5% without increased risk of bleeding. In this review, we discuss current advances in managing SIC and DIC.

Comparison of Antithrombin III and Pentoxifylline Treatments in Gram Negative Sepsis Patients Developing Disseminated Intravascular Coagulation

Objective:

The aim of this study was to evaluate the effects of antithrombin III (AT III) and pentoxifylline treatments on the gram negative septic patients with disseminated intravascular coagulation (DIC).

Method:

For six days after plasma AT III activity dropped lower than 80% in Gram-patients who developed DIC were treated with AT III (90-120 IU/kg/day in 6 hours) or pentoxifylline (1.5 mg/kg/h in 6 hours) Fibrinogen, FDP, D-dimer, complete blood count, AT III activity, and DIC scores were calculated and recorded.

Results:

The coagulation tests, AT III activity and FDP started to improve from the second day of treatment with both treatments (p<0.05). D-Dimer started to decrease on the second day of treatment with pentoxifylline (p<0.001) and fourth day of AT III treatment (p<0.05). Fibrinogen levels decreased on the second day of pentoxifylline treatment (p<0.05) and on the last day of AT III treatment (p<0.001). DIC scores started to decrease on the last day of treatment with AT III treatment (p<0.001) and on the third day of treatment with pentoxifylline (p<0.05).

Conclusion:

Both ATIII and pentoxifylline treatments had positive effects on fibrinogen, FDP, D-Dimer, AT III activity and DIC scores in patients with Gram-negative sepsis who developed DIC.

Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis

Objective: Evaluate hemostatic dysfunction in pediatric severe sepsis by thromboelastography (TEG) and determine if TEG parameters are associated with new or progressive multiple organ dysfunction syndrome (NPMODS) or shock, defined as a lactate ≥2mmol/L. We explored the relationship between TEG variables, selective cytokines, and endothelial factors. Design: Prospective observational. Setting: Single-center, quaternary care pediatric intensive care unit. Patients: Children aged 6- months to 14- years with severe sepsis with expected PICU stay for >72 h. Interventions: None. Measurements and Main Results: Twenty-eight children were enrolled with median (IQR) age of 7.3 years (4.4-11.4), PELOD score (study day-1) of 11(1.25-13), and PICU length of stay of 10 days (5-28). TEG-defined hypercoagulable state occurred most commonly in 73% (94/129) of samples, followed by hypocoagulable state in 7.8% (10/129) and mixed coagulation state in 1.5% (2/129) of samples in the study cohort. In contrast, hypocoagulable state occurred most commonly in 66% (98/148) of samples based on standard coagulation parameters. In the seven children who developed shock with NPMODS compared to eight patients with shock without NPMODS and 12 patients with severe sepsis only, we found more profound coagulopathy [thrombocytopenia (p = 0.04), elevated INR (p = 0.038), low fibrinogen level (p = 0.049), and low TEG-G value (p = 0.01)] and higher peak of interleukin-6 (p = 0.0014) and IL-10 (p = 0.007). Peak lactate in the first 5 study days had moderate correlation with standard coagulation assays, TEG parameters, and selective cytokines. Peak lactate did not correlate with markers of endothelial activation. Lowest TEG -G value had moderate correlation with peak IL-10 (ρ -0.442, p =0.019), peak VCAM (ρ - 0.495, p = 0.007), and peak lactate (ρ -0.542, p = 0.004) in the first 5 study days. A combination of TEG-G value and IL-6 concentration best discriminated children with shock and NPMODS [AUC 0.979 (95%CI 0.929-1.00), p < 0.001]. Conclusion: This exploratory analysis of hemostasis dysfunction on TEG in pediatric severe sepsis suggests that while hypercoagulability is more common, a hypocoagulable state is associated with shock and NPMODS. In addition, TEG abnormalities are also associated with immune and endothelial factors. A larger cohort study is needed to validate these findings.

Levels of circulating microparticles in septic shock and sepsis-related complications: a case-control study

BACKGROUND

Microparticles (MP) have been largely studied as potential biomarkers in septic shock (SS) though their biological and clinical relevance is still unclear. This case-control study describes the trend of various MP subtypes during SS to evaluate their possible association with severity of illness and sepsis-related complications (disseminated intravascular coagulation [DIC] and acute kidney injury [AKI]).

METHODS

Forty patients admitted to the Intensive Care Unit with SS and 40 matched healthy volunteers were recruited. AnnexinV+, E-selectin+, thrombomodulin (TM+), leukocyte-derived (CD45+, CD36+) and platelet-derived MP (PMP-expressed as PMP/platelets ratio) were measured by flow-cytometry at baseline, on day 1, 3 and 7 after diagnosis. Severity of illness was assessed by Sequential Organ Failure Assessment Score, duration of vasoactive support and mechanical ventilation. Sepsis-related complications were considered.

RESULTS

Overall, septic patients showed higher levels of all MP considered compared to controls. TM+MP were significantly lower in more severe sepsis, while CD36+MP and PMP/platelets ratio were significantly increased in patients requiring longer vasoactive support and mechanical ventilation. As for sepsis-related complications, a higher PMP/platelets ratio in patients who developed DIC and increased E-selectin+MP in subjects who developed AKI were observed. PMP/platelets ratio at baseline was significantly associated with longer vasoactive support (OR=1.59 [1.05-2.42]), longer mechanical ventilation (OR=1.6 [1.06-2.42]) and DIC occurrence (OR=1.45 [1.08-1.96]).

CONCLUSIONS

A global response through extra-vesiculation of endothelial cells, leukocytes and platelets during the early stages of SS was confirmed. The cellular activation was detected until day 3 after diagnosis. PMP/platelets ratio at diagnosis may be useful to evaluate SS severity and DIC occurrence.

Comparison of a new criteria for sepsis-induced coagulopathy and International Society on Thrombosis and Haemostasis disseminated intravascular coagulation score in critically ill patients with sepsis 3.0: a retrospective study

Recently, new criteria for sepsis-induced coagulopathy (SIC) were developed, including the sequential organ failure assessment (SOFA) criteria. The objective of this study was to evaluate the new SIC criteria in patients diagnosed with sepsis 3.0. Data from patients diagnosed with sepsis 3.0 after ICU admission were retrospectively obtained from July 2013 to June 2014. Relevant demographic, clinical, and laboratory parameters were noted. This study included 252 patients. The International Society on Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC), modified ISTH-DIC, and SIC scores were higher among nonsurvivors (P < 0.0001). The Acute Physiology and Chronic Health Evaluation II (P < 0.001), ISTH (P = 0.001), modified ISTH (P = 0.001), and SIC scores (P = 0.007) were independent predictors of ICU mortality. Using the receiver operating characteristic curve, SOFA had the greatest power for predicting ICU mortality; ISTH or modified ISTH score had greater predictive power than the SIC score. There were strong correlations between SIC score and ISTH (P < 0.0001), modified ISTH (P < 0.0001), the Acute Physiology and Chronic Health Evaluation II (P = 0.012), and SOFA (P < 0.0001) scores. More nonsurvivors were diagnosed with DIC using the ISTH and modified ISTH criteria (P < 0.001). In contrast, there was no significant difference in the proportion of patients with SIC between both groups (P = 0.055). ISTH score, modified ISTH score, and SIC score were independent risk factors for ICU mortality. Compared with the ISTH and modified ISTH scores, SIC score showed no advantage in diagnosing sepsis-associated coagulopathy or DIC. The application of these three criteria in patients with sepsis 3.0 needs further evaluation.

Newly Proposed Sepsis-Induced Coagulopathy Precedes International Society on Thrombosis and Haemostasis Overt-Disseminated Intravascular Coagulation and Predicts High Mortality

BACKGROUND

Disseminated intravascular coagulation (DIC) has been recognized as an urgent and critical condition in patients with sepsis. Therefore, unfamiliar and time-consuming tests or a complex scoring system are not suitable for diagnosis. Sepsis-induced coagulopathy (SIC), a newly proposed category delineated by a few global coagulation tests, has been established as an early warning sign for DIC. The purpose of this study was to elucidate the characteristics of SIC, especially in relation to the score of the International Society on Thrombosis and Haemostasis (ISTH) for overt DIC.

METHOD

A data set for 332 patients with sepsis who were suspected to have DIC, antithrombin activity <70%, and treated with antithrombin substitution was utilized to examine the relationship between SIC and overt DIC. The performance of SIC calculated at baseline (ie, before treatment) as well as on days 2, 4, or 7 was analyzed in terms of its ability to predict 28-day mortality and overt DIC.

RESULTS

At baseline, 149 (98.7%) of 151 patients with overt DIC according to the ISTH definition were diagnosed as having SIC. Of the 49, 46 (93.9%) patients who developed overt DIC between days 2 and 4 had received a prior diagnosis of SIC. The sensitivity of baseline SIC for the prediction of death was significantly higher than that of overt DIC (86.8% vs 64.5%, P < .001). The sensitivity of SIC on days 2, 4, and 7 was significantly higher than those of overt DIC (96.1%, 92.3%, and 84.4% vs 67.1%, 57.7%, and 50.0%, P < .001, .001, and .001, respectively), although the specificity of SIC was lower at all time points.

Sepsis-Induced Coagulopathy and Japanese Association for Acute Medicine DIC in Coagulopathic Patients with Decreased Antithrombin and Treated by Antithrombin

Disseminated intravascular coagulation (DIC) in patients with sepsis represents a critical condition. Thus, a simple and rapid diagnosis is required. The purpose of this study was to compare the performances of a recently developed Sepsis-Induced Coagulopathy (SIC) with the Japanese Association for Acute Medicine (JAAM) DIC. Four hundred nine patients with sepsis having coagulopathy and antithrombin activity of less than 70% and treated with antithrombin were retrospectively analyzed, and the SIC and JAAM-DIC criteria on days 1 (before treatment), 2, 4, and 7 were compared. The prevalence of JAAM-DIC on day 1 was significantly higher than that of SIC (91.4% vs 81.8%, P = .003), but there were no differences on days 2, 4, and 7. The mortality rates in the SIC and JAAM-DIC groups were both 23.3%. The specificity to 28-day mortality on day 1 was higher in the SIC group (15.8% vs 9.2%, P = .013). There were no differences in sensitivity on days 1, 2, 4, and 7. Mortality was significantly different between SIC-positive and SIC-negative groups on days 2, 4, and 7 (P < .01, respectively), while significant differences were seen between JAAM-DIC-positive and JAAM-DIC-negative groups only on days 4 and 7 (P < .05, .01, respectively). In summary, the SIC characteristics were similar to the JAAM-DIC group, and the classifications were comparable in terms of mortality prediction. The SIC scoring system is simple, easy to use, and adaptable to the new sepsis definitions and offers an important approach to evaluating patients in emergency and critical care settings.