New disseminated intravascular coagulation score: A useful tool to predict mortality in comparison w

1
New disseminated intravascular coagulation score
A useful tool to predict mortality in comparison
with Acute Physiology and Chronic Health
Evaluation II and Logistic Organ Dysfunction
scores

• Critical Care Medicine, Volume 34 (2), February
  2006, pp 314-320
• Date 2006/2/20

2
Background

• Disseminated Intravascular Coagulation
• A complex systemic thrombohemorrhagic disorder
• Fibrin deposition in microcirculature
• ? Ischemic tissue damage
• Consumption of coagulantion factor and PLTs
• ? Diffuse bleeding
• Most often associated with sepsis, shock, major
  trauma, malignancy (adenocarcinoma, leukemia),
  obstetric complications (abruptio placenta)
• May occur in 30-50 of patients with sepsis

3
Pathophysiology

• Tissue / endothelial injury / tumor / endotoxin
• ? Release of tissue factors / cytokines
• ? Deposition of small thrombi in
  microvasculature
• ? Consumption of coagulation factors and
• secondary fibrinolysis
• ? Procoagulants and PLT deletion,
• FDP antihemostasis

4
(No Transcript)
5
Clinical Presentation

• End organ infarction
• Altered consciousness
• Circulatory collapse, hypotension
• ARDS
• Acute renal failure, oliguria, hematuria
• Diffuse or localized thrombosis
• Acrocyanosis
• Pregangrenous change
• Hemorrhage
• GI bleeding
• Petechiae, mucosa bleeding
• Microangiopathy
• Hemolysis, Hematuria

6
Clinical Presentation

• Lab examination
• Thrombocytopenia
• Prolonged PT, aPTT
• Reduced fibrinogen level
• Elevated FDP
• Presence of D-dimer
• Blood smear schistocyte
• Treatment
• Treat the primary disease state
• Control the major symptoms thrombosis / bleeding
• Heparin, FFP, Cryoprecipitate, platelets

7
Introduction

• Scoring system for organ dysfunction
• Acute Physiology and Chronic Health Evaluation
  (APACHE) II
• Logistic Organ Dysfunction (LOD) score
• DIC / coagulation abnormalities plays only a
  minor role in these scoring system.
• However, multiple organ failure may involve DIC
  due to consumption coagulopathy or microvascular
  thrombosis.

8
Logistic Organ Dysfunction (LOD) score

• Neurologic System
• Glasgow Coma Score
• Cardiovascular System
• Heart Rate (beats/min)
• Systolic Blood Pressure
• Renal System
• Serum Urea
• Serum Urea Nitrogen
• Creatinine
• Urine Output (L/day)

• Pulmonary System
• PaO2 (mm Hg)/FiO2
• Hematologic System
• White Blood Cell Count
• Platelets (109/L)
• Hepatic System
• Bilirubin
• Prothrombin
• Total LODS Score
• Probability of Death ()

JAMA, 1996, 276(10), p.802-10
9
Scoring system for diagnosing DIC
Prothrombin Index the percentage of the present
prothrombin complex to its normal level
10
DIC scoring system

• The DIC subcommittee of the International Society
  on Thrombosis and Haemostasis, Jul 2001
• 4 variables prothrombin time (prothrombin
  index), platelet count, fibrinogen level, and a
  fibrin-related marker (D-dimer, FDP, soluble
  fibrin)
• Compare with APACHE II and LOD score to predict
  mortality

11
Methods

• Design Single-center retrospective study
• Setting Medical intensive care unit of the
  University of Munich
• Patients A total of 797 patients admitted to the
  ICU between January 1, 1996, and January 1, 2001.
• Inclusion Criteria the coagulation variables
  D-dimer, platelet count, fibrinogen, and
  prothrombin index were available within the first
  12 hrs after admission.
• Exclusion criteria missing values, missing
  admission diagnosis, fibrinolytic treatment
  before admission, vasculitis, unknown outcome due
  to transfer to other hospitals.
• Survival defined as survival at day 28 after
  admission
• LOD score counted by the worst value within the
  first 24 hrs
• Stastics SPSS version 1.0

12
(No Transcript)
13
Results

• An increasing DIC score was associated with an
  increasing mortality, especially in patients with
  serious infections.
• DIC score lt 2 low mortality (lt20)
• DIC score gt 6 high mortality (gt80)
• DIC score Survivor / Non-survivor 2.2 / 3.8,
  plt.001

14
Results

• Survival time correlated with the scoring system
  for DIC in patients with sepsis

15

• Scoring system for DIC correlated well with
  APACHE II score (r0.36) and LOD score (r0.35)

16

• The performance of the different scoring systems
  concerning mortality was similar according to the
  ROC (receiver operating characteristic) curves

17
Results

• In a Cox regression analysis using age, sex,
  coagulation variables, APACHE II, LOD, and DIC
  score as variables, only the scoring system for
  DIC and the APACHE II score remained as
  independent variables influencing the survival
  time in patients with sepsis (plt.001 odds ratio,
  1.524 95 CI, 1.226 1.894 and plt.001 odds
  ratio, 1.101 95 CI, 1.054 1.149,
  respectively)

18
Results
19
Results

• In patients of cardiovascular disease (not prone
  to DIC)
• Increasing coagulation score was associated with
  increasing mortality, decreasing survival time,
  and with increasing APACHE II score or LOD score

20
Discussion

• In patients with sepsis, the DIC scoring system
  and the established APACHE II and LOD scores show
  a positive correlation, and the diagnostic
  accuracy of the three scoring systems to predict
  mortality seems to be similar
• The Cox regression analysis showed that the DIC
  and APACHE II scores correlated independently
  with survival time, with a greater effect of the
  DIC score than the APACHE II or the Logistic
  Organ Dysfunction score
• Any state of shock, including septic or
  cardiogenic shock, leads to macrocirculatory and
  microcirculatory failure, activating coagulation
  and fibrinolysis, and becoming evenly prone to
  cause DIC

21
Discussion

• A large randomized controlled trial showed a
  reduced mortality with activated protein C
  treatment, especially in patients with high
  APACHE II scores, coagulation abnormalities and
  in overt DIC status.
• The combination of APACHE II and DIC score may
  help to predict patients who may potentially
  benefit more from this treatment option.

Efficacy and safety of recombinant human
activated protein C for severe sepsis. N Engl J
Med 2001 344(10)699-709.
22
Discussion

• Limitation of this studies
• The study design is the retrospective analysis at
  a single center
• The limited number of patients in the high range
  of scores
• These results should be confirmed in a
  prospective study

23
Conclusion

• The scoring system for DIC had an independent and
  higher impact on survival time than the APACHE II
  score
• Retrospective data suggest that a combination of
  (APACHE) II score and the scoring system for DIC
  predicts mortality in critically ill patients
  better than the APACHE II score alone, especially
  in patients with infections.

24

• Thanks For Your Attention !