Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation

A mouse model of sepsis-associated DIC induced by Kappa-carrageenan and Lipopolysaccharides: Establishment and characteristics

BACKGROUND

No animal models fully replicate the pathogenesis and clinical features of sepsis-associated disseminated intravascular coagulation (DIC), which hinders mechanistic understanding and treatment development. Kappa-carrageenan (KCG) and lipopolysaccharides (LPS) induce thrombosis and systemic inflammation in mice, respectively. The combination of LPS and KCG provides a promising method for establishing a mouse model of sepsis-associated DIC.

OBJECTIVE

This study aimed to establish a standardized mouse model of sepsis-associated DIC using KCG and LPS.

METHODS

Kunming (KM) mice were intraperitoneally injected with KCG (25-200 mg/kg) alone or in combination with LPS (50-1250 μg/kg) to determine optimal dose. The effects of ambient temperature, gender and mouse strains on the mouse model were evaluated. Time-dependent changes in the model were examined.

RESULTS

The combined injection of KCG (100 mg/kg) and LPS (50 μg/kg) effectively induced tail thrombosis and prolonged activated partial thromboplastin time. Mice housed at 16 ± 1℃ exhibited more severe thrombosis and hypocoagulability than those at 24 ± 1℃. Male and female mice exhibited similar responses. Time-course analysis revealed inflammation and blood hypocoagulability beginning from 1.5 to 24 h, with fibrinolysis inhibition occurring within 1 h. Tail thrombosis and auricle petechial developed at 3 and 6 h, respectively, and stabilized by 12 h. Thrombi in the tail, lung and liver along with organ dysfunction were obeserved at 12 h. KM and BALB/c mice exhibited longer tail thrombi than Institute of Cancer Research (ICR) mice. KM mice showed more severe blood hypocoagulability than ICR and BALB/c mice.

CONCLUSIONS

This study establishes a standardized mouse model of sepsis-associated DIC using KCG and LPS, which more accurately replicates the key clinical and pathological characteristics of sepsis-associated DIC compared to existing models. This model serves as a novelty and valuable tool for investigating the mechanisms of sepsis-associated DIC and therapeutic evaluation.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Complement system activation through the alternative pathway associates with disseminated intravascular coagulation to increase mortality in sepsis

BACKGROUND

Sepsis-induced disseminated intravascular coagulation (DIC) increases mortality in sepsis patients. Complement system activation is concomitant with sepsis-induced DIC; however, it is unclear how these two pathologies influence clinical parameters of sepsis individually and in combination, and which of the complement pathways activation is predominantly associated with mortality.

METHODS

In this ancillary analysis of a prospective observational study, 49 adult sepsis patients were assigned to four groups according to the absence/presence of DIC and complement activation. Effects of complement activation and DIC on clinical demographics including parameters of DIC, systemic severities, and 60-days all-cause mortality were assessed by comparing the groups. We analyzed each complement pathway by comparing Bb, C3a/C3 ratio, SC5b-9/C3 ratio, C4d, C4d/C4 ratio, C3a, C5a, and SC5b-9 between survivors/non-survivors both in all the patients and in the DIC+ subgroup.

RESULTS

Complement system activation induced thrombocytopenia and enhanced sepsis severity measured as APACHE2 and SOFA scores. 60-days all-cause mortality was different between groups, with 0 % in the complement activation alone group, 14 % in the DIC alone group and 66 % in the combined DIC and complement activation group. Bb and C3a/C3 and SC5b-9/C3 ratios were higher in non-survivors, with Bb and SC5b-9/C3 ratio still higher in DIC+ non-survivors.

CONCLUSION

Complement activation worsen the severity of sepsis and cause thrombocytopenia. Co-occurrence of complement activation and DIC increased sepsis mortality. The alternative pathway of complement activation plays a major role in sepsis mortality.

Acute complications and treatment in critically ill patients with 3,4-methylenedioxymetamfetamine intoxication: a 10-year retrospective observational study in an intensive care unit in an Amsterdam hospital

INTRODUCTION

The persistent increase in the use of 3,4-methylenedioxymetamfetamine has led to an increase in emergency department presentations. Our aim was to study the most frequent reasons for admission to the intensive care unit of critically ill patients with 3,4-methylenedioxymetamfetamine intoxication and to describe their complications, management and outcome.

METHODS

This retrospective cohort study included all patients with confirmed or self-reported 3,4-methylenedioxymetamfetamine intoxication admitted to the intensive care of a tertiary care hospital in Amsterdam between 2010 and 2020.

RESULTS

Seventy-four patients (73% male) were included. Three patients (4%) died. The most common reason for intensive care admission was a threatened airway (n = 35, 47%) due to trismus, which led to respiratory acidosis in 25 patients (71%). Two patients developed aspiration pneumonia, and one patient developed a pneumothorax. Seventeen patients (39%) presented with hyponatraemia, of whom 65% were treated with hypertonic saline, leading to a median serum sodium concentration correction of 13 mmol/L (IQR 7-15 mmol/L) after 8 h. Lastly, eight patients (11%) presented with hyperthermia of whom seven patients received cooling therapy. All displayed secondary complications, such as rhabdomyolysis, acute kidney injury, acute liver injury, acute liver failure and disseminated intravascular coagulation. Patients with a temperature <39 °C did not develop complications of hyperthermia.

DISCUSSION

Unlike other studies, trismus was the most common reason for intensive care unit admission in our study. Trismus, or its treatment with benzodiazepines, may lead to respiratory acidosis. The median correction of the serum sodium concentration in our population was greater than advised in the European guideline. The occurrence of osmotic demyelination was not reported.

CONCLUSION

The three most common complications of 3,4-methylenedioxymetamfetamine use necessitating intensive care admission were a threatened airway due to trismus, hyponatraemia and hyperthermia. Severe complications can arise, especially in patients presenting with hyperthermia. Although the majority of patients included in this study made a full recovery, 4% died.

Hidden threats: Brucellosis diagnosis and co-infection patterns in Crimean-Congo Hemorrhagic Fever suspects

PURPOSE

This study aims to investigate the frequency of brucellosis in patients with Crimean-Congo Hemorrhagic Fever (CCHF).

METHOD

In this study, 1231 patients were evaluated retrospectively, including 14 patients with CCHF and brucellosis coinfection and 25 patients with brucellosis alone. Statistical methods such as the Mann-Whitney U test and Fisher's exact test were used.

RESULT

Of the patients with a preliminary diagnosis of Crimean-Congo Hemorrhagic Fever (CCHF), 3.2% were found to have brucellosis. In the group co-infected with brucellosis and CCHF, the time to hospital admission was shorter. Additionally, tick exposure and headache were observed more frequently in this group. Creatine kinase levels were found to be higher in the co-infected group, while lymphocyte counts and fibrinogen levels were lower compared to the group with brucellosis alone.

CONCLUSION

Our study revealed a 3.2% rate of brucellosis in patients with a preliminary diagnosis of CCHF. Due to the similarity of symptoms and common risk factors, the differential diagnosis of brucellosis should be considered in patients diagnosed with CCHF. Additionally, the possibility of brucellosis coexisting with CCHF should always be considered. Even in patients diagnosed with CCHF, an evaluation for brucellosis must be conducted.

Disseminated intravascular coagulation and cirrhotic coagulopathy: overlap and differences. The current state of knowledge. Communication from the SSC of the ISTH

Patients with disseminated intravascular coagulation (DIC) have decreasing plasma levels of coagulation factors and platelet counts with increased levels of D-dimer. Standard laboratory tests are used clinically to diagnose DIC and quantify the severity of the disease. In patients with cirrhosis, liver-derived plasma coagulation factor levels are reduced due to decreased hepatic synthesis, further exacerbated by extravascular redistribution of these proteins, causing prolongation of routine diagnostic coagulation tests. Platelets are often decreased in cirrhosis due to reduced production and portal hypertension, resulting in hypersplenism and sequestration. Patients with cirrhosis frequently have elevated fibrin/fibrinogen degradation product levels without having acute medical decompensation. As a result, these patients commonly meet the laboratory criteria of DIC. However, it has been debated whether laboratory-assessed DIC is present in patients with cirrhosis and if it has clinical relevance. In this communication, we review hemostatic features in cirrhosis and DIC, examine published studies that evaluate the activation of hemostasis in patients with cirrhosis, and highlight future directions for research.

Utility of Sepsis-induced Coagulopathy among Disseminated Intravascular Coagulation Diagnostic Criteria: A Multicenter Retrospective Validation Study

BACKGROUND

 The criteria for diagnosing sepsis-induced coagulopathy (SIC) may overlap with those of Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC). This study determined if the diagnostic criteria of SIC overlap with JAAM DIC diagnostic criteria for identifying patients with DIC according to the International Society on Thrombosis and Haemostasis (ISTH) criteria and whether the patients diagnosed with these criteria have the same prognosis.

METHODS

 This multicenter retrospective study included patients with sepsis diagnosed using the JAAM and ISTH DIC and SIC criteria on days 1 and 4. The established ISTH DIC criteria was the reference standard for primary outcome that compared the characteristics of SIC and JAAM DIC. Secondary outcomes were multiple organ dysfunction syndrome (MODS), ventilator-free and intensive care unit-free days, and in-hospital mortality.

RESULTS

 A total of 1,438 patients were included in this study. On day 1, the JAAM DIC and SIC criteria diagnosed almost all patients with ISTH DIC (98 and 94%, respectively), predicting ISTH DIC (area under the receiver operating curve [AUC]: 0.740 versus 0.752, p = 0.523) and MODS (AUC: 0.686 versus 0.697, p = 0.546) on day 4 and progressing to ISTH DIC in the same proportion (28.6 versus 30.1%, p = 0.622). There were no differences in survival probabilities (p = 0.196) or secondary outcomes between patients diagnosed using JAAM DIC and SIC criteria on day 1.

CONCLUSION

 SIC and JAAM DIC diagnoses were equal among patients with sepsis, suggesting that SIC criteria add little to current DIC scoring systems.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024: significance of guidelines developed for each underlying disease

Disseminated intravascular coagulation (DIC) is a severe condition characterized by systemic, persistent activation of coagulation in the presence of an underlying disease, leading to the formation of microthrombi in small blood vessels. In DIC, fibrinolysis is also activated alongside coagulation, but the extent of fibrinolysis varies significantly depending on the underlying condition. The classification of DIC types is crucial not only for understanding the pathophysiology involved, but also for selecting appropriate treatment strategies. Internationally, DIC is often associated with sepsis, typically presenting with ischemic organ damage. However, it is important to recognize that some forms of DIC exhibit minimal ischemic organ damage but severe bleeding symptoms. When diagnosing and treating DIC, considering the underlying condition and disease type can lead to better clinical outcomes. This underscores the need for DIC management guidelines that are based on an understanding of the underlying disease. The newly released "Clinical Practice Guidelines for Management of Disseminated Intravascular Coagulation in Japan 2024" offer the first comprehensive guidelines for detailed management based on specific underlying conditions, providing a groundbreaking contribution to the global DIC clinical community.

Disseminated intravascular coagulation: cause, molecular mechanism, diagnosis, and therapy

Disseminated intravascular coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, resulting in both thrombosis and bleeding. This review aims to provide a comprehensive overview of DIC, emphasizing its clinical significance and the need for improved management strategies. We explore the primary causes of DIC, including sepsis, trauma, malignancies, and obstetric complications, which trigger an overactive coagulation response. At the molecular level, DIC is marked by excessive thrombin generation, leading to platelet and fibrinogen activation while simultaneously depleting clotting factors, creating a paradoxical bleeding tendency. Diagnosing DIC is challenging and relies on a combination of existing diagnostic criteria and laboratory tests. Treatment strategies focus on addressing the underlying causes and may involve supportive care, anticoagulation therapy, and other supportive measures. Recent advances in understanding the pathophysiology of DIC are paving the way for more targeted therapeutic approaches. This review highlights the critical need for ongoing research to enhance diagnostic accuracy and treatment efficacy, ultimately improving patient outcomes in those affected by DIC.

Antithrombin and Activated Protein C in Pediatric Sepsis: Prospective Observational Study of Outcome

OBJECTIVES

To assess antithrombin and activated protein C (aPC) levels in relation to disseminated intravascular coagulation (DIC) and severe outcomes in pediatric sepsis.

DESIGN

Prospective, observational study conducted between April 2023 and October 2024. Coagulation profiles including conventional coagulation, antithrombin activity, and aPC were obtained at PICU admission.

SETTING

PICU in the Vietnam National Children's Hospital, Hanoi, Vietnam.

SUBJECTS

PICU admissions, 1 month to 18 years old, with sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty children (78 males; median age 7.5 mo) with mortality 23/130 (17.7%). The prevalence of overt DIC was 37 of 130 (28.5%). Nonsurvival at 28 days, compared with survival, was associated with hemorrhage and/or thrombosis at presentation, and higher number of dysfunctional organs, and overt DIC. Those with overt DIC, compared with not, had longer activated partial thromboplastin time, higher international normalized ratio and d -dimer, and lower antithrombin, and aPC. Activity of antithrombin and aPC correlated inversely with the Vasoactive-Inotropic Score in survivors ( p = 0.002 and 0.009, respectively). Patients with a cutoff value for antithrombin less than 63.5% had a mortality risk with area under the receiver operating characteristic (AUROC) curve 0.64, with sensitivity 0.51 and specificity 0.74, and positive predictive value 0.30. Regarding overt DIC, a cutoff value for antithrombin less than 55.5% had an AUROC 0.78, sensitivity 0.72 and specificity of 0.73, and positive predictive value 0.52.

CONCLUSIONS

In this observational study of pediatric sepsis patients, first 24-hour coagulation data in those who did not-survive to 28 days, vs. survivors showed an associated prior lower level of antithrombin in nonsurvivors. Furthermore, using the outcome of overt DIC and nonovert DIC in the first 72 hours, we found that lower levels of antithrombin or aPC are each associated with overt DIC and nonovert DIC in pediatric sepsis. Further validation work is needed in larger case series of pediatric sepsis.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024: part 4-trauma, burn, obstetrics, acute pancreatitis/liver failure, and others

Disseminated intravascular coagulation (DIC) is a complex condition with diverse etiologies. While its association with sepsis has been widely studied, less focus has been given to DIC arising from other critical conditions, such as trauma, burns, acute pancreatitis, and obstetric complications. The 2024 Clinical Practice Guidelines, developed by the Japanese Society on Thrombosis and Hemostasis (JSTH), aim to fill this gap and offer comprehensive recommendations for managing DIC across various conditions. This study, Part 4 of the guideline series, addresses DIC management in trauma, burns, obstetric complications, acute pancreatitis/liver failure, viral infections, and autoimmune diseases. For trauma-associated DIC, early administration of fresh-frozen plasma (FFP), coagulation factor concentrates such as fibrinogen and prothrombin complex concentrates, and tranexamic acid is recommended. The guidelines also highlight DIC in obstetrics, which is associated with massive bleeding, and recommend the administration of fibrinogen concentrate, antithrombin concentrate, and tranexamic acid. Through a systematic review of the current evidence, the guidelines provide stratified recommendations aimed at improving clinical outcomes in DIC management beyond sepsis, thereby serving as a valuable resource for healthcare providers globally.

The diagnosis of DIC: a current overview

The name of disseminated intravascular coagulation (DIC) and its diagnostic criteria remain controversial. DIC is a clinical syndrome caused by a variety of etiologies, which determines its high heterogeneity. It is inappropriate to adopt the same diagnostic criteria. DIC has its common characteristics. First, in most DIC, thrombosis and bleeding coexist. Second, DIC is a dynamic process. Third, endothelial cell injury and systemic coagulation activation are the core of DIC. Fourth, DIC is an initiating factor of multiple organ dysfunction syndrome (MODS). There are still controversies about the diagnostic criteria of DIC. First, it relies on clinical manifestations and laboratory tests, which cannot reflect pathophysiology. Second, the clinical manifestations were not sensitive or specific. Third, there is a lack of sensitive biomarkers. Fourth, the parameters in the current diagnostic criteria cannot fully reflect the actual coagulation function. Fifth, it is obviously inappropriate to use the same scoring system for diagnosis of clinical syndromes with different etiologies and pathophysiology. Therefore, it is urgent to re-establish the diagnostic criteria for DIC. In recent years, the understanding of DIC has been continuously improved, including the in-depth understanding of the pathogenesis, the classification of coagulation phenotypes, and the development of the "two-step" diagnosis of DIC, etc. All of these contribute to the establishment of new diagnostic criteria for DIC. In conclusion, it is necessary to develop personalized diagnostic criteria based on etiology, reflecting pathophysiological mechanisms, establishing clear cut-off values for parameters, being clinical applicable, being globally unified, and most importantly, being able to identify therapeutic targets.

Coagulation abnormalities following brown recluse spider (Loxosceles reclusa) envenomation: A description of 2 cases and review of the literature

OBJECTIVE

Hemostatic abnormalities, including disseminated intravascular coagulation (DIC), are often cited as a common finding in patients following Loxosceles spider envenomation (ie, loxoscelism). The prevalence and severity of coagulopathy, however, particularly following L reclusa (ie, brown recluse) envenomation, is not well described. This study aimed to characterize coagulation laboratory parameters and coagulopathy in patients following L reclusa envenomation.

METHODS

We evaluated the coagulation laboratory parameters (eg, prothrombin time, partial thromboplastin time, coagulation factor activity levels, lupus anticoagulant [LA] testing) of 2 patients seen at our institution following brown recluse spider envenomation. We also comprehensively reviewed the literature for all reported cases of brown recluse spider envenomation and assessed patient demographics, clinical presentations, coagulation laboratory parameters, and outcomes.

RESULTS

We identified 2 patients with loxoscelism (1 cutaneous only, 1 systemic with hemolysis) with prolonged partial thromboplastin times but with normal clotting factor levels following envenomation. Literature review identified 263 patients: 12 patients had at least 1 prolonged clotting time, 31 reported a platelet count below 150 × 109/L, and there was clinical concern for DIC in 12 cases. The odds of death were statistically significantly higher in patients with clinical concern for DIC than in cases without concern for DIC or coagulopathy (odds ratio, 82.9 [95% CI, 12.6-433.8]; P < .001).

CONCLUSIONS

Following brown recluse spider envenomation, hemostatic perturbations are infrequent and clinical coagulopathy is uncommon, but the odds of death following a brown recluse spider bite are statistically significantly greater if DIC develops, even when compared to individuals with hemolysis without DIC.

Biomarkers of sepsis-induced coagulopathy: diagnostic insights and potential therapeutic implications

Diagnosing coagulopathy in septic patients remains challenging in intensive care. Disseminated intravascular coagulation (DIC) indeed presents with complex pathophysiology, complicating timely diagnosis. Epidemiological data indicate a significant prevalence of DIC in septic patients, with mortality rates up to 60%. Despite advances, current biomarker-based diagnostic tools often fail to provide early and accurate detection. This review evaluates the utility and limitations of traditional and emerging biomarkers for diagnosing sepsis-induced coagulopathy (SIC) and DIC. We also assess the effectiveness of anticoagulant therapy guided by biomarker-based diagnostic criteria.

A comparison of disseminated intravascular coagulation scoring systems and their performance to predict mortality in sepsis patients: A systematic review and meta-analysis

BACKGROUND

Disseminated intravascular coagulation (DIC) is a common complication in sepsis patients which exacerbates patient outcomes. The prevalence and outcomes of DIC in sepsis is wide-ranging and highly depends on the severity of the disease and diagnostic approaches utilized. Varied diagnostic criteria of DIC have been developed and their performance in diagnosis and prognosis is not consistent. Therefore, this study aimed to determine the score positivity rate and performance of different DIC scoring systems in predicting mortality in sepsis patients.

METHODS

Four databases, including Medline (through PubMed), Scopus, Embase, and Web of Science were searched for studies that determined DIC in sepsis patients using the three scoring systems namely: the International Society on Thrombosis and Hemostasis DIC (ISTH-DIC) criteria, the Japanese association for acute medicine DIC (JAAM-DIC) criteria, and the sepsis-induced coagulopathy (SIC) criteria. A random-effect meta-analysis was performed with a 95% confidence interval (CI). Subgroup analysis was conducted in view of geographic region and sepsis stages. the protocol was submitted to the Prospective Register for Systematic Reviews (PROSPERO) with an identifier (CRD42023409614).

RESULTS

Twenty-one studies, published between 2009 and 2024, comprising 9319 sepsis patients were included. The pooled proportion of cases diagnosed as positive using ISTH-DIC criteria, JAAM-DIC criteria, and SIC were 28% (95% CI: 24-34%), 55% (95% CI:42-70%), and 57% (95% CI: 52-78%), respectively. The pooled mortality rates were 44% (95% CI:33-53%), 37% (95% CI: 29-46%), and 35% (95% CI: 29-41%), respectively. The pooled sensitivity and specificity of ISTH-DIC to predict mortality were 0.43 (95% CI: 0.34-0.52), and 0.81 (95% CI: 0.74-0.87), respectively, while for JAAM-DIC it was 0.73 (95% CI: 0.57-0.85) and 0.46 (95% CI: 0.28-0.65), respectively. Pooled sensitivity and specificity for SIC were 0.71 (95% CI: 0.57-0.82) and 0.49 (95% CI: 0.31-0.66), respectively.

CONCLUSION

The SIC and JAAM-DIC scores exhibited higher sensitivity to identify patients with coagulopathy and predict patient outcomes, and thus are valuable to identify patients for possible treatment at an early stage. The ISTH-DIC score perhaps identified patients at later stages and demonstrated better specificity to predict disease outcomes. Thus, early identification of patients using the SIC and JAAM-DIC scores and later confirmation using the ISTH-DIC score would be beneficial approach for improved management of patients with sepsis.

Impact of hyper- and hypothermia on cellular and whole-body physiology

The incidence of heat-related illnesses and heatstroke continues to rise amidst global warming. Hyperthermia triggers inflammation, coagulation, and progressive multiorgan dysfunction, and, at levels above 40 °C, can even lead to cell death. Blood cells, particularly granulocytes and platelets, are highly sensitive to heat, which promotes proinflammatory and procoagulant changes. Key factors in heatstroke pathophysiology involve mitochondrial thermal damage and excessive oxidative stress, which drive apoptosis and necrosis. While the kinetics of cellular damage from heat have been extensively studied, the mechanisms driving heat-induced organ damage and death are not yet fully understood. Converse to hyperthermia, hypothermia is generally protective, as seen in therapeutic hypothermia. However, accidental hypothermia presents another environmental threat due to arrhythmias, cardiac arrest, and coagulopathy. From a cellular physiology perspective, hypothermia generally supports mitochondrial homeostasis and enhances cell preservation, aiding whole-body recovery following resuscitation. This review summarizes recent findings on temperature-related cellular damage and preservation and suggests future research directions for understanding the tempo-physiologic axis.

Thrombocytopenia in Critically Ill Children: A Review for Practicing Clinicians

Thrombocytopenia frequently occurs in patients before, during, and after admission to Pediatric Intensive Care Units (PICUs). In critically ill children, it is often due to multifactorial causes and can be a sign of significant organ dysfunction. This review summarizes the potential causes/mechanisms of thrombocytopenia in acutely ill children, their identification, and treatments, with special attention paid to septic patients. The mechanisms of thrombocytopenia include decreased production and sequestration, but the most common reason is increased destruction or consumption. This review specifically reviews and compares the presentation, pathogenesis, and treatment of disseminated intravascular coagulation (DIC) and the thrombotic microangiopathic spectrum (TMA), including thrombocytopenia-associated multiorgan failure (TAMOF), hemolytic uremic syndrome, and other diagnoses. The other etiologies discussed include HLH/MAS, immune thrombocytopenia, and dilutional thrombocytopenia. Finally, this review analyzes platelet transfusions, the various thresholds, and complications.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024. Part 3: solid cancers and vascular abnormalities

This study discusses disseminated intravascular coagulation (DIC) associated with solid cancers and various vascular abnormalities, both of which generally exhibit chronic DIC patterns. Solid cancers are among the most significant underlying diseases that induce DIC. However, the severity, bleeding tendency, and progression of DIC vary considerably depending on the type and stage of the cancer, making generalization difficult. Moreover, during the process of creating these guidelines, it became apparent that despite solid cancers being a major underlying condition for DIC, there is a lack of high-quality research on DIC associated with solid cancers. Nevertheless, we developed recommendations for clinical questions (CQs) regarding the use of heparin and recombinant thrombomodulin. Additionally, statements concerning these five questions were provided. DIC associated with various vascular abnormalities, is characterized by hyperfibrinolytic activity and linked to underlying conditions such as aortic aneurysm, aortic dissection, vasculitis syndromes, and vascular malformations. These conditions must always be considered differential diagnoses when unexplained thrombocytopenia or bleeding tendencies are observed. Although no evidence was found to support the assignment of recommendation levels, three statements were made. However, traumatic vascular abnormalities have not been discussed in this context.

A nomogram based on InLDH and InNLR for predicting disseminated intravascular coagulation in patients with heat stroke

Background

Heat stroke (HS), a potentially fatal heat-related illness, is often accompanied by disseminated intravascular coagulation (DIC) early, resulting in a poorer prognosis. Unfortunately, diagnosis by current DIC scores is often too late to identify DIC. This study aims to investigate the predictors and predictive model of DIC in HS to identify DIC early.

Methods

This retrospective study analyzed clinical data of patients with HS in a tertiary hospital from January 1, 2008 to December 31, 2020. Univariate and multivariate logistic regression analyses were employed to identify the risk factors for DIC in HS. The predictive models based on these risk factors were constructed and externally validated, and their predictive efficacy was evaluated using receiver operating characteristic curves.

Results

A total of 219 HS patients, including 49 with DIC, were included. The independent risk factors for DIC were identified as follows: neutrophil percentage (Neu%), lymphocyte count, lymphocyte percentage (Lym%), creatine kinase-MB (CKMB), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and rhabdomyolysis (RM). After logarithmization, the final predictive model based on the logarithm of lactate dehydrogenase (InLDH; odds ratio (OR) = 9.266, 95% confidence interval (95%CI; 4.379-19.607), p < 0.0001) and the logarithm of neutrophil-lymphocyte ratio (InNLR; OR = 3.393, 95%CI (1.834-6.277), p < 0.0001) was constructed with the largest area under the curve (0.928). A nomogram incorporating InLDH and InNLR was developed and showed excellent discrimination and calibration capabilities.

Conclusion

Nine independent risk factors were identified for the occurrence of DIC in HS patients. The predictive model based on InLDH and InNLR can effectively predict the incidence of DIC. A nomogram based on InLDH and InNLR was developed to facilitate early identification and timely treatment of DIC in HS patients.

Disseminated Intravascular Coagulation in Pediatric Acute Leukemia: Prevalence, Laboratory Features, and Prognostic Significance of ISTH Score

INTRODUCTION

Disseminated intravascular coagulation (DIC) is associated with acute leukemia. DIC prevalence and clinical consequences are complex and varies across acute leukemia subtypes. The International Society of Thrombosis and Hemostasis (ISTH) scoring system is used for the detection of overt DIC.

METHODS

Children of both sexes (1 day-18 years) with acute leukemia, suspected to have DIC and referred to hematology laboratory were included in the study. DIC score was calculated according to ISTH guidelines from laboratory values obtained within 24 h of admission and repeated after 2 weeks. The DIC cases were classified into overt DIC if ISTH score ≤ 5 and non-overt if ISTH score > 5.

RESULTS

Sixty-two children diagnosed with acute leukemia and having the clinical and laboratory diagnostic features of DIC along with 48 age-matched healthy controls participated in the study. DIC was more frequently diagnosed in cases of AML (66.13%) compared to ALL (33.87%). Cases with T-ALL had DIC (19.4%) more frequently than B-ALL type (14.5%). Similarly, children with M5, M2, and M3 had DIC more frequently (16.1%, 15.58% and 14.28%, respectively) compared to other AML types. Overt DIC was observed in 71% of DIC cases with acute leukemia while non-overt DIC was diagnosed in 29% of them. Follow-up for 14 days of non-overt cases showed that 12 out of 18 patients progressed from non-overt to overt DIC with a significant increase in D-dimer and a decline in platelets count. The incidence of bleeding (35.4%) was higher than thrombosis (19.4%) among acute leukemia patients with DIC. An ISTH score ≤ 5 predicted increased intensive care unit (ICU) admission, death and end organ dysfunction with odds ratio of 4.28, 6.77, and 6.67, respectively. Based on receiver-operator analysis of DIC cases classified as overt and non-overt DIC based on ISTH score, D-Dimer was excellent predictor of overt DIC with the high sensitivity and specificity.

CONCLUSION

ISTH score predicts death, ICU admission and organ dysfunction in children with acute leukemia. D-Dimer is an excellent predictor of overt DIC in acute leukemia.

Disseminated intravascular coagulation is associated with a poor outcome in patients with out-of-hospital cardiac arrest receiving VA-ECMO

We tested the hypothesis that disseminated intravascular coagulation (DIC) predicts a poor prognosis in patients with out-of-hospital cardiac arrest (OHCA) treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Fifty-seven patients with cardiogenic OHCA who immediately underwent VA-ECMO upon admission to the emergency department were divided into 27 non-DIC and 30 DIC patients. DIC scores were calculated on admission and 24 h later (day 1). The primary outcome measure was the all-cause in-hospital mortality. The basic characteristics did not differ between the two groups; however, patients with DIC showed higher in-hospital mortality rates. Receiver operating characteristic curve analysis showed a moderate predictive ability of DIC scores on day 1 for in-hospital mortality. A lower probability of survival was observed in patients with DIC. The adjusted odds ratio for DIC on day 1 of in-hospital death was 5.67, confirmed by the adjusted hazard ratio of 3.472. The results indicate an association between DIC diagnosis 24 h following VA-ECMO induction for OHCA and poor outcome in these patients.

Effect of hypofibrinolysis on clinical outcomes of patients with septic disseminated intravascular coagulation

BACKGROUND

This study investigated the utility of thromboelastometry (ROTEM) in assessing hypofibrinolysis among septic patients, specifically the association of hypofibrinolysis, as determined by ROTEM, with septic disseminated intravascular coagulation (DIC), organ dysfunction, and clinical outcomes.

METHODS

This single-center, retrospective analysis included adult septic patients admitted to Saga University Hospital from 2013 to 2017, with available ROTEM data. Hypofibrinolysis was assessed using the lysis index at 60 min (LI60) in extrinsic thromboelastometry (EXTEM). Based on their LI60 values, patients were classified into three groups: Hyper (LI60 ≤ 85), Normal (LI60 86-96), and Hypo (LI60 ≥ 97).

RESULTS

Among the 63 cases analyzed, the Hypo group showed significantly higher APACHEII and SOFA scores than the Normal group, indicating greater disease severity. Similarly, DIC and sepsis-induced coagulopathy (SIC) scores were notably higher in the Hypo group. The diagnostic performance of LI60 for ISTH-overt DIC showed an area under the curve (AUC) of 0.954, with an optimal cutoff value of 97 %, achieving 100 % sensitivity and 83.3 % specificity. The odds ratio for ISTH-overt DIC was 2.894, indicating a strong association between elevated LI60 and occurrence of DIC. Hypofibrinolysis predicted 28-day mortality and high SOFA scores (≥ 10) with high specificity and negative predictive value (NPV). A Kaplan-Meier curve revealed that the Hypo Group showed significantly worse clinical outcomes than the Normal and Hyper groups.

CONCLUSION

For septic patients, fibrinolysis suppression presenting as "hypofibrinolysis" (elevated LI60) is associated with poor prognosis and risk of higher organ dysfunction. Moreover, it is a significant predictor of adverse clinical outcomes in sepsis.

Risk Factors and Predictive Model for Disseminated Intravascular Coagulation in Patients with Multiple Myeloma

OBJECTIVES

Multiple myeloma (MM) is a hematologic malignancy comprising approximately 10% of all blood cancers. Patients with MM are at risk for disseminated intravascular coagulation (DIC), a serious complication characterized by systemic coagulation activation, leading to microthrombi, organ dysfunction, and severe bleeding. This study aims to investigate the incidence of DIC among MM patients and identify risk factors associated with DIC development. We also sought to develop a predictive formula for assessing DIC risk.

METHODS

A retrospective analysis was conducted on MM patients. Logistic regression analysis was used to identify factors significantly associated with DIC. The predictive power of the logistic regression model was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

The incidence of DIC among hospitalized MM patients was 16.8%. Significant factors identified by logistic regression analysis included prothrombin time (PT), fibrin degradation products (FDP), and D-dimer levels. ROC curve analysis indicated that the predictive model had strong discriminatory power, with an area under the curve (AUC) of 0.927. A predictive formula for the probability of DIC occurrence was developed based on the logistic regression model.

CONCLUSIONS

The predictive formula developed in this study offers a tool for early identification of MM patients at high risk of DIC. While the model demonstrates strong predictive capability, further validation and refinement are required to improve its accuracy and clinical application.

Prevalence and clinical impact of disseminated intravascular coagulation in acute aortic dissection: a nationwide cohort study

Background

Acute aortic dissection is a life-threatening cardiovascular emergency with high mortality rates. Disseminated intravascular coagulation (DIC) is a critical complication in patients with acute aortic dissection; however, its incidence and impact on outcomes remain inconclusive.

Objectives

This study aimed to evaluate DIC prevalence and prognosis in patients with aortic dissection.

Methods

We conducted a multicenter retrospective cohort study using data from the Japan Medical Data Center claims database between 2014 and 2022. DIC was diagnosed based on the criteria of the Japanese Association for Acute Medicine (JAAM-2) and the International Society on Thrombosis and Haemostasis (ISTH). We compared the in-hospital mortality between patients with and without DIC and assessed the impact of coagulopathy using various coagulation profiles.

Results

Among the 3037 patients, 40% underwent surgery and 60% did not undergo surgery. The prevalence rates of JAAM-2 DIC and ISTH DIC were 21% and 9.4%, respectively. In-hospital mortality was significantly higher in the DIC group than in the non-DIC group, and this trend was consistently observed in the surgery and nonsurgery groups. Increased DIC scores correlated with higher in-hospital mortality. With the progression of coagulopathy, characterized by thrombocytopenia, elevated prothrombin time-international normalized ratio, prolonged activated partial thromboplastin time, increased D-dimer, and decreased fibrinogen levels, in-hospital mortality also increased.

Conclusion

The presence of DIC, as identified by both the JAAM-2 and ISTH criteria, was associated with increased in-hospital mortality in patients with acute aortic dissection. Therefore, further studies are needed to improve the clinical outcomes of these patients.

Subcutaneous Hematoma Elevates Plasma Levels of FDP and D-Dimer; an Analysis by Animal Model Experiments

Purpose

Trauma-associated coagulopathy has been considered to develop as a result of increased fibrinolysis due to massive bleeding, tissue damage and hypoperfusion. However, it has not been investigated whether hematoma may cause trauma-associated coagulopathy. Using experimental animal model, we analyzed the effects of hematoma formation on coagulation and fibrinolysis parameters.

Materials

Male Wistar rats were used for the studies.

Methods

We made an animal model of subcutaneous hematoma without tissue injuries. This model can be categorised as a kind of trauma models. We created experimentally subcutaneous hematomas in test animals using blood collected from other animals. We performed blood sampling to measure blood cell counts and coagulation parameters from test animals at 1, 6, 24, 48 and 96 hours after hematoma generation. Blood samples were collected and immediately sent for measurement of CBC, Prothrombin, FDP, D-dimer, Fibrinogen, Antithrombin, AST and ALT. Furthermore, after 1, 24 and 48 hours, we performed dynamic evaluation of coagulation/fibrinolysis function using thromboelastometry method.

Results

After the hematoma were created, FDP and D-dimer increased over time, and reached a plateau after 48 hours. During the period, there was no decrease in Fibrinogen and Antithrombin, and no thrombocytopenia occurred. Moreover, no obvious changes in coagulation/fibrinolysis function were observed employing thromboelastometry.

Discussion

Elevated FDP and D-dimer after hematoma creation are assumed to be synthesized in the hematoma, not in the streaming blood. Thromboelastometry also shows that elevated levels of FDP and D-dimer are not caused by intravascular coagulation and subsequent fibrinolysis.

Conclusion

The study showed that subcutaneous hematomas caused increases in FDP and D-dimer levels, without activating the blood coagulation/fibrinolysis system.

The transition of the criteria for disseminated intravascular coagulation and the targeted patients in randomized controlled trials over the decades: a scoping review

BACKGROUND

Disseminated intravascular coagulation (DIC) is a severe complication in septic patients. The Japanese Ministry of Health and Welfare (JMHW)-DIC criteria, the first DIC criteria, were established in 1983, and several other criteria have been proposed since then, including the International Society on Thrombosis and Haemostasis (ISTH)-overt DIC criteria and the Japanese Association for Acute Medicine (JAAM) DIC criteria. This study aimed to look into the transition of DIC criteria used in randomized controlled trials (RCTs) for sepsis-induced DIC.

METHODS

We searched PubMed, Scopus, and the Cochrane Central Register of Controlled Trials for English-language studies published through September 30, 2023. Two reviewers looked through citations that assessed the DIC criteria used in RCTs and their secondary analyses. Data on DIC diagnostic criteria, patient characteristics, interventions, and results were gathered.

RESULTS

Twenty-one studies (thirteen RCTs: JMHW-DIC in 5, JAAM-DIC in 4, the sepsis-induced coagulopathy (SIC) in 2; and eight secondary analyses: ISTH-overt DIC in 3, single parameter in 5) were eligible for inclusion. Most RCTs were conducted in Japan, using the criteria of JMHW-DIC, which were followed by JAAM-DIC. Recently, SIC has been used in international RCTs. Meanwhile, other countries tended to conduct RCTs that focused on sepsis, with secondary analyses for DIC using the ISTH-overt DIC criteria.

CONCLUSIONS

The criteria used in RCTs have changed over decades, from the JMHW-DIC to the JAAM-DIC criteria, and the ISTH-overt DIC criteria were retained in the secondary analysis. Based on these findings, additional research is needed to determine the best criterion for diagnosing septic patients.

Risk Factors for Venous Thromboembolism in Acute Promyelocytic Leukemia

BACKGROUND

Acute promyelocytic leukemia (APL) is frequently associated with disseminated intravascular coagulation (DIC), leading to potentially life-threatening bleeding. Compared to bleeding, thromboses are a less commonly encountered problem.

OBJECTIVE

The objective of our study was to identify the incidence and predictive value of demographic data, clinical-laboratory parameters, and thrombosis risk assessment models (RAMs) for venous thromboembolism (VTE) in patients with APL.

METHODS

This study was a retrospective study conducted on adult patients with APL who were treated between 2006 and 2024 at the Clinic of Hematology UCCS with all-trans retinoic acid (ATRA) and anthracycline. The demographic and clinical-laboratory data related to VTE were collected and analyzed alongside the predictive value of two RAMs proposed by Al-Ani and Paterno and colleagues.

RESULTS

Among the one-hundred-fifty-five adult patients with APL, VTE was diagnosed in twenty-eight cases (18.1%). The most common location for thrombosis was in the central venous catheter (CVC), which affected twelve (42.8%) patients. A total of six (21.4%) patients had deep vein thrombosis (DVT), one patient (3.6%) showed a pulmonary embolism (PE), and thrombosis at unusual sites was present in nine (32.1%) patients. Our analyses showed that neither Al-Ani's RAM nor the RAM proposed by Paterno and colleagues were predictive for VTE in patients with APL. The C statistics value for the Al-Ani model was ROC = 0.514, and, for Paterno's RAM, it was ROC = 0.521. The independent risk factors for VTE, identified via multivariate analysis, were CD114 expression (p = 0.005, OR = 6.4 IC 95%: [1.8-23.2]) and the absence of bleeding at presentation (p = 0.013, OR = 0.086 IC 95%: [0.01-0.59]).

CONCLUSIONS

To the best of our knowledge, this is the first study showing that a higher expression of CD114 increases the risk of VTE. The absence of bleeding at presentation in patients with APL correlates with thrombosis. Further analyses are needed to confirm these findings and help to develop therapeutic strategies to prevent VTE complications. So far, no risk assessment model has been sufficient to stratify patients with APL according to their risk of VTE.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024. Part 1: sepsis

The Japanese Society on Thrombosis and Hemostasis (JSTH) published the first-ever disseminated intravascular coagulation (DIC) guidelines in 2009. Fifteen years later, the JSTH developed new guidelines covering DIC associated with various underlying conditions. These guidelines were developed in accordance with the GRADE system to determine the strength of the recommendations and certainty of the evidence. This article was drafted as Part 1 of an overall DIC guideline covering various underlying conditions, with sepsis as the subject. In this section, seven key clinical issues (questions) are set. Question 1, regarding DIC diagnosis, introduces several diagnostic criteria, such as the JAAM-2, ISTH overt, SIC, and JSTH DIC criteria and recommends choosing the appropriate diagnostic criteria for DIC based on an understanding of their diagnostic properties. For pharmacotherapy in DIC patients with sepsis, we recommend the administration of antithrombin (Question 2) and recombinant thrombomodulin (Question 3) (both GRADE 1B). However, we do not make a clear recommendation regarding the administration of heparin (Question 6) and serine protease inhibitors (Question 7) because of the lack of evidence. Combination therapy, order of administration, and other administration methods for antithrombin and recombinant thrombomodulin are proposed as important future research questions (Questions 4 and 5).

Emergencies in Hematology: Why, When and How I Treat?

Hematological emergencies are critical medical conditions that require immediate attention due to their rapid progression and life-threatening nature. As various examples, hypercalcemia, often associated with cancers such as multiple myeloma, can lead to severe neurological and cardiac dysfunction. Hyperleukocytosis, common in acute myeloid leukemias, increases the risk of leukostasis and multiorgan failure. Sickle cell crisis, a common complication in sickle cell disease, results from vaso-occlusion, leading to acute pain and tissue ischemia. Tumor lysis syndrome, reported in cases of rapid destruction of cancer cells, causes electrolyte imbalances and acute kidney injury. Acute transfusion reactions, fundamental in hematological conditions, can range from mild allergic responses to severe hemolysis and shock, requiring prompt management. Disseminated intravascular coagulation, involving excessive coagulation and bleeding, is commonly triggered by hematological malignancies, common in the first phases of acute promyelocytic leukemia. Recently, in the era of bispecific antibodies and chimeric antigen receptor T cells, cytokine release syndrome is a manifestation that must be recognized and promptly treated. Understanding the pathophysiology, recognizing the clinical manifestations, and ensuring adequate diagnostic strategies and management approaches for each condition are central to early intervention in improving patient outcomes and reducing mortality.

Time trends of outcome and treatment options for disseminated intravascular coagulation from 2010 to 2021 in Japan: A nationwide observational study

INTRODUCTION

Mortality and changes in treatment options for disseminated intravascular coagulation (DIC) are trending downward. This study investigated temporal trends in mortality and treatment preferences of several anticoagulants in Japan.

METHODS

This retrospective observational study used the Japanese Diagnosis Procedure Combination inpatient database containing data from >1500 acute-care Japanese hospitals. All adult patients diagnosed as having DIC from July 2010 to March 2022 were sorted by predefined underlying conditions: sepsis, solid cancer, leukemia, trauma, or obstetric. We evaluated in-hospital mortality and clinical status of anticoagulant use for DIC treatment.

RESULTS

Baseline characteristics of the 443,098 DIC patients showed increased age, worsened comorbid conditions, and higher illness severity over time. Over the 12 years, in-hospital mortality for overall DIC patients declined by 17 % from 42.0 % (95 % CI 41.4-42.5 %) to 34.7 % (95 % CI 34.1-35.3 %) (Ptrend < 0.001). This downward decrease was more evident in patients with sepsis (17 %), solid cancer (18 %), and leukemia (22 %) but was not clinically meaningful in trauma and obstetrics patients. The trend in treatment preferences of anticoagulants for DIC patients also changed. Recombinant thrombomodulin administration increased dramatically from 2011 to 2015 and remained high through 2021. Only 7 % of DIC patients were administered antithrombin and recombinant thrombomodulin concomitantly, and its use continues to decline.

CONCLUSIONS

All-cause in-hospital mortality for DIC patients clearly decrease by 17 % over the study period. Anticoagulant therapy for patients with DIC has been decreasing, possibly due to recent published clinical evidence.

Heparin-binding protein and sepsis-induced coagulopathy: Modulation of coagulation and fibrinolysis via the TGF-β signalling pathway

BACKGROUND

Heparin-binding protein (HBP) levels have been linked to organ failure and may represent an inflammatory biomarker of sepsis. We found disseminated intravascular coagulation (DIC) is associated with higher HBP levels in patients and in in vivo and in vitro models. This prospective, single-center observational study investigated the effects and underlying mechanisms of HBP on the coagulation cascade in sepsis.

METHODS

538 patients with sepsis from June 2016 to December 2019 were enrolled. Mechanisms underlying HBP and the coagulation system were investigated in human umbilical vein endothelial cells (HUVEC) and C57 mice.

RESULTS

Increased HBP was associated with sepsis-induced DIC. The optimal cutoff value was 37.5 ng/mL (sensitivity: 56 %, specificity: 65 %). Antithrombin-III (AT-III) activity, plasmin-a2 plasmin inhibitor complex (PIC), procalcitonin (PCT), hemoglobin, and HBP ≥37.5 ng/mL were associated with of DIC occurrence. In HUVECs &C57 mice models, Western blotting, qPCR, and immunohistochemistry analysis showed that the binding between HBP and TGF-β receptor 2 (TGFBR2) caused elevation of plasminogen activator inhibitor-1 (PAI-1) levels. Furthermore, we found that mice stimulated with HBP had higher levels of fibrinogen and D-dimer in the blood. HBP treatment caused the accumulation of fibrinogen in mice lung tissue. Treatment with TGFBR2-small interfering RNAs inhibited the effects.

CONCLUSION

Patients with sepsis having HBP ≥37.5 ng/mL at admission were more likely to develop DIC. HBP upregulates the expression of fibrinogen and PAI-1 via TGFBR2 and the TGF-β signalling pathway.

Effect of colistin combined with sulbactam: 9 g versus 12 g per day on mortality in the treatment of carbapenems resistant Acinetobacter baumannii pneumonia: A randomized controlled trial

BACKGROUND

The current treatment recommendation involves administering a high dose of sulbactam alongside at least one additional agent. However, there remains a lack of data regarding the optimal dosage of sulbactam. We investigated whether administering sulbactam at a dosage of 12 g/day decreases the mortality rate among patients with CRAB pneumonia compared to 9 g/day.

METHODS

The study was an open-label, superiority, randomized controlled trial conducted at Phramongkutklao Hospital between September 2019 and September 2023 in patients diagnosed with CRAB. Participants were randomly assigned to receive a combination of colistin with either 9 or 12 g/day of sulbactam. The primary endpoint was the all-cause mortality rate at 28 days postrandomization.

RESULTS

Among the 138 participants, there was a trend towards a lower mortality rate in the 12 g/day group (59.4% vs. 47.8%; P = 0.158). After adjusting for factors associated with mortality, a lower mortality was observed in the 12 g/day group (adjusted HR 0.54 [95% CI 0.33-0.87]; P = 0.0110). The microbiological cure rate at day 7 was higher in the 12 g/day group (73.2% vs. 89.4%; P = 0.02).

CONCLUSIONS

Colistin in combination with sulbactam at a dosage of 12 g/day may improve mortality compared to 9 g/day.

Negative expression of CD117 predicted inferior OS and PFS in acute promyelocytic leukemia

INTRODUCTION

In recent years, the correlation between CD117 antigen and the prognosis of hematological malignancies has been demonstrated. However, there is limited literature on the clinical significance of CD117 antigen in acute promyelocytic leukemia (APL). The aim of this study was to retrospectively analyze the clinical features and prognostic significance of CD117 in APL.

METHODS

In this study, we retrospectively investigated the clinicopathological characteristics, outcome, and prognostic impact of negative CD117 expression (CD117-) in 169 APL patients treated with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) containing regimen.

RESULTS

The median follow-up period was 63.0 months. CD117- was detected in 13 APL patients (7.7%). No significant differences were found in baseline characteristics between CD117+ and CD117- subgroups. However, compared to CD117+ APL, the incidence of early death (ED) was significantly higher in CD117- APL (p = 0.023). By multivariate analysis, CD117- was an independent adverse prognostic factor for overall survival (OS) and progression-free survival (PFS) (p = 0.022 and p = 0.014, respectively).

CONCLUSIONS

To sum up, CD117- is associated with greater risk of ED and has the statistical power to predict inferior OS and PFS, this marker may be considered to build prognostic scores for risk-adapted therapeutic strategies in APL management.

Clot Waveform Analysis: From Hypercoagulability to Hypocoagulability: A Review

CONTEXT.—

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are coagulative screening tests used for the diagnosis of several pathologic conditions, such as liver failure, coagulation factor deficiencies, anti-phospholipid antibodies (lupus anticoagulant), and factor VIII inhibitors. A new test was developed several years ago to detect the amount of thrombin generated during plasma clotting, using low tissue factor concentrations and fluorogenic substrates, and it has since been used successfully in conditions ranging from hypocoagulable to hypercoagulable states. However, the test is expensive and difficult to perform in nonspecialized laboratories, and efforts have thus been made to find an economic and easily implementable test suitable for routine use, even in nonspecialist laboratories.

OBJECTIVE.—

To evaluate clot waveform analysis (CWA) of PT and aPTT, aiming to show the dynamics of clot formation; that is, the "hidden" features of both tests. CWA can be implemented by using an automated coagulometer with dedicated software. The aim of this review was to evaluate whether CWA is able to detect both hypercoagulative and hypocoagulative states.

DATA SOURCES.—

Using MedLine, we searched and retrieved articles relating to CWA. We only considered articles published in English, but with no limits in terms of article type, publication year, or geography.

CONCLUSIONS.—

CWA was shown to be a reliable test in patients with both hypercoagulable and hypocoagulable states. It represents a simple and inexpensive global test that can easily provide information on the behavior of the coagulation system. Both the first and second derivatives are computed by using dedicated software implemented with an on-board algorithm in a routine automated coagulometer.

Association of endotheliopathy with coagulofibrinolytic reactions and disseminated intravascular coagulation after trauma: a retrospective observational study

We carried out a retrospective observational investigation to explore the association of endotheliopathy with coagulofibrinolytic reactions and the progression of disseminated intravascular coagulation (DIC) in adult trauma patients. We measured syndecan-1 (SDC-1), an indicator of endotheliopathy, and biomarkers of coagulofibrinolysis in 100 trauma patients immediately transferred to Ehime University Hospital. We evaluated the correlations between the coagulofibrinolytic parameters and SDC-1. We also investigated the association between SDC-1 elevations and the development of DIC, and determined the discriminators of DIC development. The median SDC-1 concentration was 82.7 (43.5-178.1) ng/mL. DIC developed in 16 patients (16.0%), and SDC-1 concentrations were significantly higher in DIC patients than in non-DIC patients (218.8 [134.5-798.2] ng/mL vs. 67.2 [39.6-114.5] ng/mL, p < 0.001). Receiver operating characteristic curve analysis revealed that the circulating SDC-1 level effectively predicted the progression of DIC, with an area under the curve of 0.862 (95% confidence interval [CI], 0.789-0.936). The optimal cut-off value was determined to be 92.5 ng/mL, yielding a sensitivity of 100.0% and a specificity of 67.8% (p < 0.001). A simple logistic regression analysis showed that a circulating SDC-1 concentration of > 92.5 ng/mL was significantly correlated with DIC progression (odds ratio [OR], 31.67; 95%CI: 3.97-252.31, p = 0.001). Many coagulofibrinolytic parameters were significantly correlated with SDC-1. Estimating the discriminators of DIC development by the least absolute shrinkage and selection operator (LASSO) and elastic-net regression analysis identified markers of coagulofibrinolytic activation, such as thrombin-antithrombin complex (TAT) and tissue plasminogen activator (tPA). A multivariate logistic regression model using TAT, tPA, and SDC-1 demonstrated that TAT and tPA, but not SDC-1, were independent factors predicting the development of DIC (TAT per 10 µg/L: OR, 1.14, 95%CI: 1.05-1.24, p = 0.003; tPA per 100pg/mL: OR, 1.03, 95%CI: 1.01-1.05, p = 0.003; SDC-1 per 10ng/mL: OR, 1.00, 95%CI: 0.99-1.01, p = 0.973). Mediation analysis showed that SDC-1 elevation was predominantly associated with the development of DIC indirectly through the increase in TAT (proportion mediated = 96.1%, p < 0.001), while there was no significant indirect effect of SDC-1 elevation on the role of TAT elevation in DIC development was observed (p = 0.340). The primary pathogenesis of DIC in the acute phase of trauma is likely driven by coagulofibrinolytic activation. Endotheliopathy, as reflected by elevated circulating levels of SDC-1, is strongly associated with coagulofibrinolytic responses. Although endotheliopathy may contribute to the early development of DIC through coagulation activation, its role appears to be limited.

Machine learning models can predict cancer-associated disseminated intravascular coagulation in critically ill colorectal cancer patients

Background

Due to its complex pathogenesis, the assessment of cancer-associated disseminated intravascular coagulation (DIC) is challenging. We aimed to develop a machine learning (ML) model to predict overt DIC in critically ill colorectal cancer (CRC) patients using clinical features and laboratory indicators.

Methods

This retrospective study enrolled consecutive CRC patients admitted to the intensive care unit from January 2018 to December 2023. Four ML algorithms were used to construct predictive models using 5-fold cross-validation. The models' performance in predicting overt DIC and 30-day mortality was evaluated using the area under the receiver operating characteristic curve (ROC-AUC) and Cox regression analysis. The performance of three established scoring systems, ISTH DIC-2001, ISTH DIC-2018, and JAAM DIC, was also assessed for survival prediction and served as benchmarks for model comparison.

Results

A total of 2,766 patients were enrolled, with 699 (25.3%) diagnosed with overt DIC according to ISTH DIC-2001, 1,023 (36.9%) according to ISTH DIC-2018, and 662 (23.9%) according to JAAM DIC. The extreme gradient boosting (XGB) model outperformed others in DIC prediction (ROC-AUC: 0.848; 95% CI: 0.818-0.878; p < 0.01) and mortality prediction (ROC-AUC: 0.708; 95% CI: 0.646-0.768; p < 0.01). The three DIC scores predicted 30-day mortality with ROC-AUCs of 0.658 for ISTH DIC-2001, 0.692 for ISTH DIC-2018, and 0.673 for JAAM DIC.

Conclusion

The results indicate that ML models, particularly the XGB model, can serve as effective tools for predicting overt DIC in critically ill CRC patients. This offers a promising approach to improving clinical decision-making in this high-risk group.

Validity of Diagnosis of Disseminated Intravascular Coagulation Based on International Classification of Diseases Coding in a Claims Database

BACKGROUND

 Accuracy in diagnoses recorded using the International Classification of Diseases (ICD) coding is the most important element ensuring the foundation of research using real-world data analyses.

OBJECTIVE

 To evaluate the validity of ICD coding for diagnoses of disseminated intravascular coagulation (DIC) using the International Society on Thrombosis and Haemostasis (ISTH) overt DIC criteria and the Japanese Association for Acute Medicine (JAAM) DIC criteria as reference standards.

METHODS

 This retrospective observational study included adult hospitalized patients diagnosed as having diseases potentially causing DIC extracted from a part of a large-scale database in Japan. The index test was a diagnosis of DIC based on the ICD-10 codes. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using ISTH overt DIC criteria and JAAM-2 DIC criteria as the reference standards. We also conducted subgroup analyses according to the underlying diseases.

RESULTS

 We included 84,300 patients in this study. In the overall study population, sensitivity, specificity, PPV, and NPV of the ICD-based diagnosis for ISTH criteria were 26.28, 98.10, 35.12, and 97.14%, respectively. In subgroup analyses according to the underlying disease, sensitivity ranged from 9.48 to 52.08%, and specificity ranged from 96.94 to 99.47%. The accuracy of the ICD-based diagnosis for JAAM-2 criteria was similar to that for ISTH criteria.

CONCLUSION

 Identification of DIC patients using ICD-10 codes had relatively low sensitivity but very high specificity for DIC diagnostic criteria. Approximately 65% of patients identified by ICD coding are likely to meet the JAAM-2 DIC criteria.

Arterial Complications Assessed by Duplex Ultrasound After Decannulation of Peripheral Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Vascular complications are common and can be fatal even after successful decannulation in patients with peripherally cannulated veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, we aimed to accurately determine the incidence of arterial complications assessed by Duplex ultrasound following peripheral VA-ECMO decannulation. In addition, we investigated the predictors of severe complications requiring intervention.

METHODS AND RESULTS

We retrospectively reviewed 1,350 adult patients who underwent ECMO between January 2012 and April 2023. Of 839 patients treated with peripherally cannulated VA-ECMO, 596 were successfully weaned off and 212 underwent Duplex ultrasound for final analysis. The primary outcome was arterial complications requiring vascular intervention. Thirty-three (15.6%) patients experienced such complications after decannulation. Acute limb ischemia due to thrombotic occlusion was the most common complication, occurring in 23 (10.8%) patients, followed by stenosis (3.8%), pseudoaneurysm (3.8%), arteriovenous fistula (0.9%), and dissection (0.9%). No significant differences in complication rates were found between the percutaneous and surgical decannulation groups in the propensity score-matched population (12.7% vs. 15.9%, respectively; P=0.799). Multivariable analysis revealed disseminated intravascular coagulation (DIC; odds ratio 2.6; 95% confidence interval 1.17-5.69; P=0.019) as the only predictor of arterial complications after decannulation.

CONCLUSIONS

Arterial complications requiring vascular intervention frequently occur following successful weaning from VA-ECMO regardless of the decannulation strategy. In this setting, DIC appears to be associated with an increased rate of arterial complications.

Proposal and Validation of a Clinically Relevant Modification of the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation Diagnostic Criteria for Sepsis

BACKGROUND

 Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria were launched nearly 20 years ago. Following the revised conceptual definition of sepsis and subsequent omission of systemic inflammatory response syndrome (SIRS) score from the latest sepsis diagnostic criteria, we omitted the SIRS score and proposed a modified version of JAAM DIC criteria, the JAAM-2 DIC criteria.

OBJECTIVES

 To validate and compare performance between new JAAM-2 DIC criteria and conventional JAAM DIC criteria for sepsis.

METHODS

 We used three datasets containing adult sepsis patients from a multicenter nationwide Japanese cohort study (J-septic DIC, FORECAST, and SPICE-ICU registries). JAAM-2 DIC criteria omitted the SIRS score and set the cutoff value at ≥3 points. Receiver operating characteristic (ROC) analyses were performed between the two DIC criteria to evaluate prognostic value. Associations between in-hospital mortality and anticoagulant therapy according to DIC status were analyzed using propensity score weighting to compare significance of the criteria in determining introduction of anticoagulants against sepsis.

RESULTS

 Final study cohorts of the datasets included 2,154, 1,065, and 608 sepsis patients, respectively. ROC analysis revealed that curves for both JAAM and JAAM-2 DIC criteria as predictors of in-hospital mortality were almost consistent. Survival curves for the anticoagulant and control groups in the propensity score-weighted prediction model diagnosed using the two criteria were also almost entirely consistent.

CONCLUSION

 JAAM-2 DIC criteria were equivalent to JAAM DIC criteria regarding prognostic and diagnostic values for initiating anticoagulation. The newly proposed JAAM-2 DIC criteria could be potentially alternative criteria for sepsis management.

Study on Preclinical Safety and Toxic Mechanism of Human Umbilical Cord Mesenchymal Stem Cells in F344RG Rats

Mesenchymal stem cells have made remarkable progress in recent years. Many studies have reported that human umbilical cord mesenchymal stem cells (hUC-MSCs) have no toxicity, but thromboembolism appeared in patients treated with hUC-MSCs. Therefore, people are still worried about the safety of clinical application. The study aims to determine the safety, potential toxic mechanism and biodistribution of hUC-MSCs. F344RG rats were given 5 or 50 million cells/kg of hUC-MSCs by single administration in compliance with Good Laboratory Practice standards. Standard toxicity was performed. RNA sequencing was then performed to explore the potential toxic mechanisms. In parallel, the biodistribution of hUC-MSCs was examined. The dose of 5 million cells/kg hUC-MSCs had no obvious toxicity on symptom, weight, food intake, hematology, serum biochemistry, urine biochemistry, cytokines, and histopathology. However, blood-tinged secretions in the urethral orifice and 20% mortality occurred at 50 million cells/kg. Disseminated intravascular coagulopathy (DIC) is the leading cause of death. hUC-MSCs significantly upregulated complement and coagulation cascade pathways gene expression, resulting in DIC. Besides, hUC-MSCs upregulated fibrinolytic system suppressor genes A2m, Serping1 and Serpinf2. hUC-MSCs survived in rats for less than 28 days, no hUC-MSC was detected in tissues outside the lungs. There was no toxicity in F344RG rats at 5 million cells/kg, but some toxicities were detected at 50 million cells/kg. hUC-MSCs significantly upregulated complement and coagulation cascade pathways, upregulated the expression of fibrinolytic system suppressor genes A2m, Serping1 and Serpinf2, to inhibit fibrinolytic system, caused DIC, which provided a new insight into the toxic mechanism of hUC-MSCs.

Rapid diagnosis of coagulopathies from vitamin K deficiency in a consecutive case cohort evaluated by comparative assessment of factor II by 1-stage assays with prothrombin time vs Ecarin reagents

BACKGROUND

Vitamin K (VK) deficiency (VKD) impairs γ-carboxylation of VK-dependent factors (VKDFs), resulting in higher factor (F)II levels measured by Ecarin (FIIE) reagents (that convert des-γ-carboxylated FII to meizothrombin) than by prothrombin time (FII) reagents.

OBJECTIVES

To evaluate FII/FIIE abnormalities among patients assessed for coagulopathies and identify findings predictive of coagulopathy improvement after VK.

METHODS

We retrospectively assessed consecutive cases from 2002 to 2021 with FII/FIIE tests and the sensitivity and specificity of FII/FIIE ratios and FIIE-FII differences for VKD defined as international normalized ratio correction/improvement of ≥0.5 after VK.

RESULTS

Two hundred ninety-two patients (males, 58.2%; adults, 85.6%; median age, 73 years) were evaluated (84.2% hospitalized, 48.3% in intensive care, 71.6% with active liver disease, and 28% deceased at discharge) and 25% to 38% had FII/FIIE findings suggestive of VKD. Among 170 patients assessed for response to VK, FII/FIIE ratios of ≤0.84 to 0.91 and FIIE-FII differences of >0.04 U/mL had similar modest sensitivity (47.7%-69.3%) and modest to good specificity (67.1%-91.5%) for VKD. FII/FIIE ratios of <0.86, suggestive of VKD (sensitivity, 47.7%; specificity, 90.2%), were more common in patients deficient in only VKDF (P = .0001), but were detected in 16% with non-VKDF deficiencies. Low FIIE was commonly associated with active liver disease (P = .0002). Patients with and without probable VKD (based on FII/FIIE ratios of <0.86) had similar mortality, bleeding, and rates of prothrombin complex concentrate and red cell transfusions (P ≥ .78), but fewer with probable VKD received plasma and fibrinogen replacement (P ≤ .024).

CONCLUSION

FII/FIIE comparison aids the diagnosis of VKD and predicts clinical responses to VK treatment among patients with coagulopathies.

A Predictive Model for Disseminated Intravascular Coagulopathy in Sepsis: An Observational Study

Introduction

Sepsis remains a significant global health challenge due to its high morbidity and mortality rates. Disseminated Intravascular Coagulopathy (DIC) represents a critical complication of sepsis, contributing to increased mortality and economic burden. Despite various prognostic scoring systems, there is a lack of a specific model for DIC prediction in sepsis patients.

Methods

This observational study included 336 sepsis patients. Clinical and laboratory data were collected, and prognoses were defined according to established criteria.

Results

We enrolled 336 patients, with 304 in the non-DIC group and 32 in the DIC group. Patients with DIC had notably lower platelet (PLT) and higher levels of prothrombin time (PT), lactate (LAC), and procalcitonin (PCT) compared to those without DIC. Univariate and multivariate analyses identified risk factors associated with the DIC, showing that PLT (OR = 0.985, 95% CI 0.978-0.993, p < 0.001), PT level (OR = 1.140, 95% CI 1.004-1.295, p = 0.044), and LAC (OR = 1.101, 95% CI 0.989-1.226, p = 0.078) were related factors. A risk model was established, and its sensitivity and specificity in predicting DIC among sepsis patients were assessed by comparing it to the SOFA score. The area under the ROC curve for the model was 0.850, while the SOFA score was 0.813. With a model score >-2.12, the sensitivity for predicting DIC was 84.4%, and the specificity was 75.0%.

Conclusion

Our study introduces a predictive model for DIC detection in sepsis patients, emphasizing the need for clinicians to focus on patients with high model scores for timely intervention.

Detection of Thrombosis Using Soluble C-Type Lectin-like Receptor-2 with D-Dimer Level and Platelet Count

Introduction: Soluble C-type lectin-like receptor -2 (sCLEC-2) has been recognized as a marker of platelet activation, and attention has been drawn to formulas combining sCLEC-2 levels with platelet count and D-dimer levels. Methods: In this study, sCLEC-2 levels, as well as sCLEC-2/platelet count (sCLEC-2/PLT), sCLEC-2 × D-dimer (sCLEC-2xDD), and sCLEc-2xDD/PLT formulas were used to detect thrombotic diseases, including microvascular thrombosis (MVT), arterial thromboembolism (ATE), and venous thromboembolism (VTE), with the aim of evaluating the ability of the three parameters combined in these formulas to diagnose thrombotic diseases. Results: The plasma sCLEC-2 levels were significantly higher in patients with infectious or thrombotic diseases than in those with neither thrombosis nor infection; however, there was no significant difference among patients with infection, ATE, VTE, and MVT; the correlations among sCLEC-2, platelet count, and D-dimer level were poor. The sCLEC-2/PLT ratio was the highest in patients with MVT, and the sCLEC-2 × D-dimer value was higher in patients with MVT and VTE than in those with neither thrombosis nor infection. Although receiver operating characteristic (ROC) analysis shows the differential diagnosis of thrombotic diseases from non-thrombosis without infection, the sCLEC-2 × D-dimer/platelet count was useful for differential diagnosis among MVT and infection or non-thrombotic diseases. Conclusions: sCLEC-2 is useful for the diagnosis of thrombosis, and the formulas of sCLEC-2 with platelet count or D-dimer are useful for the diagnosis of thrombosis using ROC analyses for the thrombosis group vs. the non-thrombosis group without infection.

Obstetric and neonatal outcomes in pregnancies complicated by placental abruption with vs. without supporting sonographic findings- A retrospective cohort study

INTRODUCTION

Placental abruption (PA) is a major obstetric complication associated with worse maternal and neonatal outcomes. Though ultrasound findings may support the diagnosis of PA, the association of such findings to the severity of PA and maternal and neonatal outcomes is not yet clear. We aimed to assess the maternal and neonatal outcomes of PA cases with vs. without related sonographic findings.

METHODS

In this retrospective cohort study, all deliveries complicated by PA between 2009 and 2022 were included. Placental histopathology, obstetric, and neonatal outcomes were compared between cases of PA with vs. without supporting sonographic findings. A composite of severe neonatal morbidity was compared between the groups, including ≥1 of the following: seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, periventricular leukomalacia, respiratory-distress syndrome, sepsis, anemia, blood transfusion or death.

RESULTS

Of the 420 cases with PA eligible for the study, 50 patients (12 %) were in the PA with sonographic features group and 370 (88 %) were in the PA without sonographic features group. The PA with sonographic features group was characterized by significantly higher rates of prematurity (p < 0.001), severe composite adverse neonatal outcome (p < 0.01), and a composite maternal vascular malperfusion lesions in placental histopathology (p = 0.001) In multivariable regression analyses, preterm birth was independently associated with the presence of sonographic features (aOR = 8.79, 95 % CI 2.41-31.93, p < 0.001).

DISCUSSION

PA with supporting sonographic features is associated with higher rates of adverse obstetric and neonatal outcomes and placental lesions. These findings emphasize the importance of sonographic evaluation for every case of PA before deciding upon management.

Understanding, assessing and treating immune, endothelial and haemostasis dysfunctions in bacterial sepsis

The interplay between the immune system, coagulation, and endothelium is critical in regulating the host response to infection. However, in sepsis and other critical illnesses, a dysregulated immune response can lead to excessive alterations in these mechanisms, resulting in coagulopathy, endothelial dysfunction, and multi-organ dysfunction. This review aims to provide a comprehensive analysis of the pathophysiological mechanisms that govern the complex interplay between immune dysfunction, endothelial dysfunction, and coagulation in sepsis. It emphasises clinical significance, evaluation methods, and potential therapeutic interventions. Understanding these mechanisms is essential for developing effective treatments that can modulate the immune response, mitigate thrombosis, restore endothelial function, and ultimately improve patient survival.

Cerebral Microbleeds in Critically Ill Patients with Respiratory Failure or Sepsis: A Scoping Review

BACKGROUND

Cerebral microbleeds (CMBs) have been described in critically ill patients with respiratory failure, acute respiratory distress syndrome (ARDS), or sepsis. This scoping review aimed to systematically summarize existing literature on critical illness-associated CMBs.

METHODS

Studies reporting on adults admitted to the intensive care unit for respiratory failure, ARDS, or sepsis with evidence of CMBs on magnetic resonance imaging were included for review following a systematic search across five databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science) and a two-stage screening process. Studies were excluded if patients' CMBs were clearly explained by another process of neurological injury.

RESULTS

Forty-eight studies reporting on 216 critically ill patients (mean age 57.9, 18.4% female) with CMBs were included. Of 216, 197 (91.2%) patients developed respiratory failure or ARDS, five (2.3%) patients developed sepsis, and 14 (6.5%) patients developed both respiratory failure and sepsis. Of 211 patients with respiratory failure, 160 (75.8%) patients had coronavirus disease 2019. The prevalence of CMBs among critically ill patients with respiratory failure or ARDS was 30.0% (111 of 370 patients in cohort studies). The corpus callosum and juxtacortical area were the most frequently involved sites for CMBs (64.8% and 41.7% of all 216 patients, respectively). Functional outcomes were only reported in 48 patients, among whom 31 (64.6%) were independent at discharge, four (8.3%) were dependent at discharge, and 13 (27.1%) did not survive until discharge. Cognitive outcomes were only reported in 11 of 216 patients (5.1%), all of whom showed cognitive deficits (nine patients with executive dysfunction and two patients with memory deficits).

CONCLUSIONS

Cerebral microbleeds are commonly reported in patients with critical illness due to respiratory failure, ARDS, or sepsis. CMBs had a predilection for the corpus callosum and juxtacortical area, which may be specific to critical illness-associated CMBs. Functional and cognitive outcomes of these lesions are largely unknown.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.