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

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

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

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

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

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.

Logistic Organ Dysfunction (LOD) score

Neurologic System
Glasgow Coma Score

Pulmonary System
PaO2 (mm Hg)/FiO2

Cardiovascular System
Heart Rate (beats/min) Systolic Blood Pressure

Hematologic System
White Blood Cell Count Platelets (10^9/L)

Renal System
Serum Urea Serum Urea Nitrogen Creatinine Urine Output (L/day)

Hepatic System
Bilirubin Prothrombin

Total LODS Score Probability of Death (%)

JAMA, 1996, 276(10), p.802-10

Scoring system for diagnosing DIC

Prothrombin Index: the percentage of the present prothrombin complex to its normal level

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

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

Results
An increasing DIC score was associated with an increasing mortality, especially in patients with serious infections.
DIC score < 2 : low mortality (<20%) DIC score > 6 : high mortality (>80%) DIC score: Survivor / Nonsurvivor = 2.2 / 3.8, p<.001

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

Scoring system for DIC correlated well with APACHE II score (r=0.36) and LOD score (r=0.35)

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

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 (p<.001 [odds ratio, 1.524; 95% CI, 1.226 1.894] and p<.001 [odds ratio, 1.101; 95% CI, 1.054 1.149], respectively)

Results

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

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

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.

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

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.

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