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

Coagulative Biomarkers Differently Predict Clinical Outcomes in Invasive Infections Caused by Neisseria Meningitidis and Streptococcus Pneumoniae

BACKGROUND

Coagulation plays a crucial role in innate immune response to invasive infections. Coagulative biomarkers might predict clinical outcomes differently, depending on etiology.

METHODS

A retrospective study was conducted during a 79-month period, recruiting 90 patients with meningitis or bloodstream infection caused by Neisseria meningitidis (n = 47) or Streptococcus pneumoniae (n = 43), median age 19 and 58 years, respectively. Biomarkers were assessed within 24 hours.

RESULTS

For N. meningitidis: in univariate analysis, increasing D-dimer was associated with in-hospital mortality (odds ratio [OR] 1.360; 95% confidence interval [CI], 1.063-1.889); in multivariate regression, increasing D-dimer was predictive (OR 1.037; 95% CI, 1.001-1.074) of the composite outcome (in-hospital mortality or amputations or hearing loss or neurological sequelae); protein C showed a clear trend toward lower levels in nonsurvivors (26% vs 48%) and in patients with the composite outcome (32% vs 51%); activated partial thromboplastin time (aPTT) was significantly prolonged in nonsurvivors (51.3 vs 35.3 seconds, P = .003), confirmed in univariate analysis (OR 1.122; 95% CI, 1.031-1.253). For S. pneumoniae: antithrombin was significantly lower in nonsurvivors (70% vs 81%, P = .038), confirmed in univariate analysis (OR 0.961; 95% CI, 0.921-0.997). For overall population: in multivariate regression, increasing age was associated with mortality (OR 1.043; 95% CI, 1.010-1.077), and S. pneumoniae etiology with the composite outcome (OR 6.024; 95% CI, 1.798-20.180).

CONCLUSIONS

For invasive infections caused by N. meningitidis, D-dimer is a biomarker capable of predicting unfavorable clinical outcomes; a potential role is suggested for aPTT prolongation and protein C decrease, and, in case of S. pneumoniae infections, for antithrombin decrease.

Impending sepsis-induced coagulopathy (SIC) is associated with increased disease severity in SIC-negative patients: a secondary analysis of a prospective exploratory study

Due to the intense crosstalk between the coagulation and immune systems, coagulation disorders are an integral part of the disturbed host response to infection that defines sepsis. These so-called sepsis-induced coagulopathies (SIC) are associated with increased morbidity and mortality. However, we still do not know enough about the prevalence and risk factors for SIC in different patient groups. In this study, we present a secondary analysis of a prospective, observational study. The objectives of this secondary analysis were (1) to estimate the prevalence of SIC at the onset of sepsis, (2) to assess the prevalence of SIC throughout the intensive care unit (ICU) stay using a previously described modified SIC score, and (3) to evaluate the association between SIC and morbidity and mortality. The prevalence of SIC at the onset of sepsis was 15.0% (95% confidence interval [CI]: 9.3-23.3%). A total of 24 additional patients who were SIC-negative at the onset of sepsis developed SIC according to the modified SIC score during their ICU stay. In total, we estimated that 39.0% (95% CI: 30.0-48.8%) of patients experienced relevant SIC during their ICU stay. Septic shock, a high lactate level, and a high Sequential Organ Failure Assessment (SOFA) score at the onset of sepsis in SIC-negative patients were associated with SIC development during the course of the disease. These findings need to be verified in larger cohorts and may represent a starting point for the development of a new screening tool for the identification of patients with sepsis at high risk of developing SIC.

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.

[A clinical investigation of constructing a diagnostic model for sepsis-induced coagulopathy utilizing data-independent acquisition proteomics]

Objective: This study used data-independent acquisition (DIA) proteomics to analyze plasma protein expression in sepsis-induced coagulopathy (SIC), identify key biomarkers, and develop a diagnostic model. Methods: This prospective study included 46 adult sepsis patients from the intensive care unit. Patients were categorized into a general sepsis group (n=26) and an SIC group (n=20) based on established SIC criteria. Plasma samples underwent proteomic and bioinformatics analyses to identify differentially expressed protein (DEP) using LASSO regression and Random Forest. A diagnostic model was constructed and assessed via receiver operating characteristic (ROC) curve analysis. Results: The baseline data revealed that SIC patients exhibited longer prothrombin times, lower platelet counts, and higher D-dimer, fibrin degradation products, blood lactate, SOFA scores, and APACHE Ⅱ scores compared with general sepsis patients (P<0.05). DIA proteomics identified 2 637 proteins, with 240 DEP meeting the criteria (fold change >1.5, P<0.05), including 81 upregulated and 159 downregulated DEP. Subcellular localization analysis revealed that DEPs were predominantly extracellular and nuclear. Gene ontology (GO) annotation showed that DEP were mainly involved in cellular physiology, biological regulation, and stress response processes in biological processes. Domain annotation revealed a predominance of immunoglobulin V regions in DEP, which are crucial for antigen recognition and binding. KEGG enrichment analysis showed significant enrichment of DEP in pathways related to natural killer cell-mediated cytotoxicity, glycosylphosphatidylinositol anchor biosynthesis, tumor necrosis factor signaling, and NF-κB signaling. LASSO regression identified angiogenin and C-type lectin domain family 10 member A as key DEP. The SIC diagnostic nomogram showed an area under the curve of 0.896, with 0.731 specificity and 0.900 sensitivity. Conclusion: The nomogram incorporating angiogenin and C-type lectin domain family 10 member A provides an accurate tool for SIC diagnosis.

Correlation of serum H-FABP, sTREM-1, and HMGB1 levels with severity and prognosis of sepsis

OBJECTIVE

To investigate the correlation between serum levels of Heart-type fatty acid binding protein (H-FABP), Soluble Triggering Receptor Expressed on Myeloid Cells 1 (sTREM-1), and High mobility group box 1 protein (HMGB1) with disease severity, and their prognostic value in sepsis.

METHODS

A retrospective analysis was conducted using the clinical data from 86 sepsis patients admitted to West China Hospital of Sichuan University between June 2021 and December 2023, and these cases constituted the observation group. In addition, clinical data from 80 healthy individuals who underwent medical examinations at our hospital during the same period served as the control group. Serum levels of H-FABP, sTREM-1, and HMGB1 were measured in both groups. Based on disease severity, the patients were categorized into mild (n=42), severe (n=28), and shock (n=16) groups. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score was used to assess the patients' condition. Follow-up evaluations showed that 60 patients survived and 26 died.

RESULTS

Serum levels of H-FABP, sTREM-1, and HMGB1 were significantly higher in the observation group compared to the control group (all P<0.05). Among the sepsis patients, the severe and shock groups exhibited significantly elevated levels of H-FABP, sTREM-1, and HMGB1 compared to the mild group, with the shock group showing the highest levels (all P<0.05). The levels of H-FABP, sTREM-1, and HMGB1 were positively correlated with APACHE II scores (r=0.760, r=0.715, r=0.709, all P<0.001). Furthermore, the levels of these biomarkers were significantly higher in patients who died than in survivors (all P<0.05). The AUCs of H-FABP, sTREM-1, and HMGB1 for predicting prognosis were 0.786, 0.790, and 0.781, respectively. Their combined prediction yielded an AUC of 0.834. Log-rank test showed that the survival time of patients with different expression levels of sTREM-1 (<856.50 pg/ml, ≥856.50 pg/ml) and HMGB1 (<395.80 ng/ml, ≥395.80 ng/ml) were significantly different (P<0.05).

CONCLUSION

Serum levels of H-FABP, sTREM-1, and HMGB1 are elevated in sepsis patients and closely associated with the disease severity, making them valuable biomarkers for monitoring the severity of sepsis. Combined detection of serum H-FABP, sTREM-1, and HMGB1 shows promising prognostic value in sepsis, with lower levels of sTREM-1 and HMGB1 linked to improved survival.

Sepsis-induced coagulopathy (SIC) in the management of sepsis

The mortality rate of sepsis remains high and further increases when complicated by disseminated intravascular coagulation (DIC). Consequently, early detection and appropriate management of DIC will be helpful for the management of sepsis. Although overt DIC criteria are often used for diagnosing definitive DIC, it was not designed to detect early-phase DIC. The criteria and scoring system for sepsis-induced coagulopathy (SIC) were developed and introduced in 2017 to detect early-stage DIC, and they were subsequently adopted by the International Society on Thrombosis and Haemostasis in 2019. The objective of detecting SIC was not to miss the patients at high risk of developing overt DIC at an earlier time. Although anticoagulant therapies are potential options for the treatment of sepsis-associated DIC, their effectiveness has not been established, and further research is warranted. For that purpose, an international collaborative platform is required for future clinical trials, and SIC criteria have been suggested for such studies. Calculating the SIC score is straightforward and suitable for use in clinical settings. This review aims to introduce SIC criteria and its scoring system for better management of sepsis-associated DIC. We also intended to update the current knowledge regarding this novel diagnostic criterion.

Improving predictions: Enhancing in-hospital mortality forecast for ICU patients with sepsis-induced coagulopathy using a stacking ensemble model

The incidence of sepsis-induced coagulopathy (SIC) is high, leading to increased mortality rates and prolonged hospitalization and intensive care unit (ICU) stays. Early identification of SIC patients at risk of in-hospital mortality can improve patient prognosis. The objective of this study is to develop and validate machine learning (ML) models to dynamically predict in-hospital mortality risk in SIC patients. A ML model is established based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database to predict in-hospital mortality in SIC patients. Utilizing univariate feature selection for feature screening. The optimal model was determined by calculating the area under the curve (AUC) with a 95% confidence interval (CI). The optimal model was interpreted using Shapley Additive Explanation (SHAP) values. Among the 3112 SIC patients included in MIMIC-IV, a total of 757 (25%) patients experienced mortality during their ICU stay. Univariate feature selection helps us to pick out the 20 most critical variables from the original feature. Among the 10 developed machine learning models, the stacking ensemble model exhibited the highest AUC (0.795, 95% CI: 0.763-0.827). Anion gap and age emerged as the most significant features for predicting the mortality risk in SIC. In this study, an ML model was constructed that exhibited excellent performance in predicting in-hospital mortality risk in SIC patients. Specifically, the stacking ensemble model demonstrated superior predictive ability.

Sepsis-Induced Coagulopathy: A Comprehensive Narrative Review of Pathophysiology, Clinical Presentation, Diagnosis, and Management Strategies

Physiological hemostasis is a balance between pro- and anticoagulant pathways, and in sepsis, this equilibrium is disturbed, resulting in systemic thrombin generation, impaired anticoagulant activity, and suppression of fibrinolysis, a condition termed sepsis-induced coagulopathy (SIC). SIC is a common complication, being present in 24% of patients with sepsis and 66% of patients with septic shock, and is often associated with poor clinical outcomes and high mortality. 1 , 2 Recent preclinical and clinical studies have generated new insights into the molecular pathogenesis of SIC. In this article, we analyze the complex pathophysiology of SIC with a focus on the role of procoagulant innate immune signaling in hemostatic activation--tissue factor production, thrombin generation, endotheliopathy, and impaired antithrombotic functions. We also review clinical presentations of SIC, the diagnostic scoring system and laboratory tests, the current standard of care, and clinical trials evaluating the efficacies of anticoagulant therapies.

Persistent high sepsis-induced coagulopathy and sequential organ failure assessment scores can predict the 28-day mortality of patients with sepsis: A prospective study

BACKGROUND

The performance of the sepsis-induced coagulopathy (SIC) and sequential organ failure assessment (SOFA) scores in predicting the prognoses of patients with sepsis has been validated. This study aimed to investigate the time course of SIC and SOFA scores and their association with outcomes in patients with sepsis.

METHODS

This prospective study enrolled 209 patients with sepsis admitted to the emergency department. The SIC and SOFA scores of the patients were assessed on days 1, 2, and 4. Patients were categorized into survivor or non-survivor groups based on their 28-day survival. We conducted a generalized estimating equation analysis to evaluate the time course of SIC and SOFA scores and the corresponding differences between the two groups. The predictive value of SIC and SOFA scores at different time points for sepsis prognosis was evaluated.

RESULTS

In the non-survivor group, SIC and SOFA scores gradually increased during the first 4 days (P < 0.05). In the survivor group, the SIC and SOFA scores on day 2 were significantly higher than those on day 1 (P < 0.05); however, they decreased on day 4, dropping below the levels observed on day 1 (P < 0.05). The non-survivors showed higher SIC scores on days 2 (P < 0.05) and 4 (P < 0.001) than the survivors, whereas no significant differences were found between the two groups on day 1 (P > 0.05). The performance of SIC scores on day 4 for predicting mortality was more accurate than that on day 2, with areas under the curve of 0.749 (95% confidence interval [CI]: 0.674-0.823), and 0.601 (95% CI: 0.524-0.679), respectively. The SIC scores demonstrated comparable predictive accuracy for 28-day mortality to the SOFA scores on days 2 and 4. Cox proportional hazards models indicated that SIC on day 4 (hazard ratio [HR] = 3.736; 95% CI: 2.025-6.891) was an independent risk factor for 28-day mortality.

CONCLUSIONS

The time course of SIC and SOFA scores differed between surviving and non-surviving patients with sepsis, and persistent high SIC and SOFA scores can predict 28-day mortality.

Comparison between sepsis-induced coagulopathy and sepsis-associated coagulopathy criteria in identifying sepsis-associated disseminated intravascular coagulation

BACKGROUND

Disseminated intravascular coagulation (DIC) is associated with increased mortality in sepsis patients. In this study, we aimed to assess the clinical ability of sepsis-induced coagulopathy (SIC) and sepsis-associated coagulopathy (SAC) criteria in identifying overt-DIC and pre-DIC status in sepsis patients.

METHODS

Data from 419 sepsis patients were retrospectively collected from July 2018 to December 2022. The performances of the SIC and SAC were assessed to identify overt-DIC on days 1, 3, 7, or 14. The SIC status or SIC score on day 1, the SAC status or SAC score on day 1, and the sum of the SIC or SAC scores on days 1 and 3 were compared in terms of their ability to identify pre-DIC. The SIC or SAC status on day 1 was evaluated as a pre-DIC indicator for anticoagulant initiation.

RESULTS

On day 1, the incidences of coagulopathy according to overt-DIC, SIC and SAC criteria were 11.7%, 22.0% and 31.5%, respectively. The specificity of SIC for identifying overt-DIC was significantly higher than that of the SAC criteria from day 1 to day 14 (P<0.05). On day 1, the SIC score with a cut-off value > 3 had a significantly higher sensitivity (72.00%) and area under the curve (AUC) (0.69) in identifying pre-DIC than did the SIC or SAC status (sensitivity: SIC status 44.00%, SAC status 52.00%; AUC: SIC status 0.62, SAC status 0.61). The sum of the SIC scores on days 1 and 3 had a higher AUC value for identifying the pre-DIC state than that of SAC (0.79 vs. 0.69, P<0.001). Favorable effects of anticoagulant therapy were observed in SIC (adjusted hazard ratio [HR]=0.216, 95% confidence interval [95% CI]: 0.060-0.783, P=0.018) and SAC (adjusted HR=0.146, 95% CI: 0.041-0.513, P=0.003).

CONCLUSION

The SIC and SAC seem to be valuable for predicting overt-DIC. The sum of SIC scores on days 1 and 3 has the potential to help identify pre-DIC.

Risk Factors of Sepsis-Associated Thrombocytopenia among Patients with Sepsis Induced Coagulopathy

The study aims to evaluate the prognosis and risk factors of sepsis-associated thrombocytopenia (SAT) among patients with coagulopathy, and to provide evidence of the relationship between adverse outcomes and potential risks. Patients with sepsis-associated coagulopathy were included in the study from January 2014 to December 2022. The primary outcome was sepsis-associated thrombocytopenia (platelet count less than 100 *109/L), which was evaluated by logistic regression models adjusted for demographic characteristics and comorbidities. Among patients in the SAT group, 54% developed severe SAT, while 16% of these patients recovered from thrombocytopenia. The in-hospital mortality rate was significantly higher in the SAT group compared to the non-SAT group (31% in SAT group vs 23.9% in non-SAT group, p = 0.029). Even after adjusting for age, gender, Charlson comorbidity, white blood cell, and Sequential Organ Failure Assessment score, the differences in mortality rate persisted (Odds Ratio 0.72, [95% Confidence Interval 0.52-0.92]). Correlation analyses revealed that prothrombin time (r = 0.08, p = 0.50), international normalized ratio (r = 0.08, p = 0.42), prothrombin activity (r = -0.06, p > 0.999), D-dimer (r = -0.02, p > 0.999), and inflammatory parameters such as C-reactive protein (r = -0.11, p = 0.37) were not significantly correlated with platelet counts. According to subgroup analyses, patients with lung infection complicated by SAT had slightly higher mortality (OR 0.66, [95% CI, 0.46 to 0.94]). Sepsis-associated coagulopathy indicates a subset of critical ill patients, with those experiencing thrombocytopenia at greater risk for in-hospital death compared to those without it.

It's in the blood: a review of the hematological system in SARS-CoV-2-associated COVID-19

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19.

The International Society of Thrombosis and Hemostasis (ISTH) criteria in intensive care units

BACKGROUND

Disseminated Intravascular Coagulation (DIC) has been assessed by the International Society of Thrombosis and Hemostasis (ISTH) 2001 and the ISTH 2018-modified version. More investigations are needed to assess usability and visibility of those DIC scoring systems in the intensive care units (ICU).

AIMS

This study investigated the predictive performance of the ISTH-Overt DIC versions of 28-day mortality in ICUs compared to SOFA as a gold standard assessment tool of sepsis.

METHODS

A retrospective design (2015-2017) included 220 adult patients enrolled from medical and surgical ICUs in two major hospitals in Jordan. We calculated ISTH-Overt DIC scores and SOFA score on time of DIC diagnosis. Overt DIC was categorized based on a score of ≥ five for ISTH DIC 2001; and ≥ 4 for ISTH DIC 2018. Provided, a score > 12 was categorized as Multiple-Organ- Dysfunction-Syndrome (MODS) for Sequential Organ Failure Assessment (SOFA) score. Then, 28-day mortality follow-up was performed.

RESULTS

More than half of sample died before 28-days of follow-up. The analysis of Receiver Operating Characteristic (ROC) showed that higher scores of ISTH DIC 2001(≥ 5), ISTH DIC 2018 (≥ 4), and SOFA score (>12) were highly associated with 28-day mortality. The ISTH DIC 2001 and SOFA score were superior on the modified ISTH 2018 in predicting 28-day mortality, with an Area Under the Curve (AUC) of (0.724 vs. 0.822 vs. 0.507, respectively). Yet, the accuracy of the SOFA score was better than the ISTH DIC 2001.

CONCLUSION

This study suggests that ISTH DIC 2001 score is helpful when applied on medical and surgical ICU Jordanian populations. It showed better results compared to the Modified ISTH DIC 2018 in mortality prediction, regardless of the underlying diseases.

Management of patients on antithrombotic therapy with severe infections: a joint clinical consensus statement of the ESC Working Group on Thrombosis, the ESC Working Group on Atherosclerosis and Vascular Biology, and the International Society on Thrombosis and Haemostasis

Patients with severe infections and a pre-existing indication for antithrombotic therapy, i.e. antiplatelet agents, anticoagulant drugs, or their combinations, require integrated clinical counselling among coagulation, infectious disease, and cardiology specialists, due to sepsis-induced coagulopathy that frequently occurs. Bacterial and viral pathogens constitute an increasing threat to global public health, especially for patients with ongoing antithrombotic treatment who have a high risk of thrombotic recurrences and high susceptibility to severe infections with increased morbidity and mortality. Similarly, sepsis survivors are at increased risk for major vascular events. Coagulopathy, which often complicates severe infections, is associated with a high mortality and obligates clinicians to adjust antithrombotic drug type and dosing to avoid bleeding while preventing thrombotic complications. This clinical consensus statement reviews the best available evidence to provide expert opinion and statements on the management of patients hospitalized for severe bacterial or viral infections with a pre-existing indication for antithrombotic therapy (single or combined), in whom sepsis-induced coagulopathy is often observed. Balancing the risk of thrombosis and bleeding in these patients and preventing infections with vaccines, if available, are crucial to prevent events or improve outcomes and prognosis.

Prognostic Impact of the International Society on Thrombosis and Hemostasis Disseminated Intravascular Coagulation Score in Sepsis: A Systematic Review

The International Society on Thrombosis and Haemostasis (ISTH) diagnostic criteria for disseminated intravascular coagulation (DIC) are widely used for DIC diagnosis. However, the prognostic value of the score may vary between different patient populations and settings. This systematic review investigated the association between the ISTH DIC score and mortality in sepsis patients. A literature search was conducted in PubMed and Embase. Inclusion criteria were studies including adult and pediatric patients hospitalized with sepsis, using any sepsis definition, and investigating the association between mortality and the ISTH DIC score. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. In total, 42 studies were included. A positive association between the ISTH DIC score and mortality was consistently reported, with odds ratios of death in DIC versus non-DIC patients ranging from 1.125 (95% confidence interval [CI]: 0.838-1.511) to 21.008 (95% CI: 1.408-313.405) in adults and from 1.378 (95% CI: 1.004-1.893) to 2.99 (95% CI: 0.54-16.6) in pediatric populations. However, the DIC score only had a low-moderate positive predictive value for mortality, as area under receiver-operator characteristics ranged from 0.602 (95% CI: 0.575-0.630) to 0.815 (95% CI: 0.676-0.954) in adults. Of note, only few studies adjusted for potential confounders such as age, gender, and comorbidity. The ISTH DIC score is consistently associated with sepsis-related mortality but is not a strong positive predictor for mortality. Nevertheless, the score may still have a prognostic value and its use in sepsis is encouraged.

The prevalence of sepsis-induced coagulopathy in patients with sepsis - a secondary analysis of two German multicenter randomized controlled trials

BACKGROUND

Sepsis and septic shock are frequently accompanied by coagulopathy. Since the sepsis-induced coagulopathy (SIC) score was first described, subsequent studies from Asia revealed a SIC prevalence of 40-60%. In Europe, however, SIC prevalence in patients fulfilling sepsis criteria according to the third international consensus definition (SEPSIS-3) has not yet been evaluated.

METHODS

The Critical Care Trials Group of the German Sepsis Competence Network (SepNet) conducted a secondary analysis of two randomized controlled trials. Only patients fulfilling sepsis criteria according SEPSIS-3 were included in this secondary analysis. In a two step approach, SIC prevalence was determined in 267 patients with sepsis but not septic shock (at the time of inclusion) from the "Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis" (HYPRESS) trial. Then, we estimated SIC prevalence in 1,018 patients from the "Effect of Sodium Selenite Administration and Procalcitonin-Guided Therapy on Mortality in Patients With Severe Sepsis or Septic Shock" (SISPCT) trial using a simplified SIC score based on the platelet-SIC-subscore (PSSC). Study aims were to assess (i) the prevalence of SIC in patients with SEPSIS-3, (ii) the association of SIC with 90-day mortality and morbidity, (iii) the time when patients become SIC positive during the course of sepsis, and (iv) the value of the PSSC for predicting SIC.

RESULTS

In the HYPRESS trial, SIC prevalence was 22.1% (95% confidence interval [CI] 17.5-27.5%). The estimated SIC prevalence in the SISPCT trial was 24.2% (95% CI 21.6-26.9%). In the HYPRESS trial, SIC was associated with significantly higher 90-day mortality (13.9% vs. 26.8%, p = 0.027) and morbidity. Logistic regression analysis adjusted for age, sex, treatment arm, and (SIC-adapted) SOFA score confirmed the negative association of SIC with survival (p = 0.011). In the SISPCT trial, increased PSSCs were associated with higher 90-day mortality (PSSC 0: 34.4%, PSSC 1: 40.5%, PSSC 2: 53.3%; p < 0.001). In both trials, SIC was already present at sepsis diagnosis or occurred during the following 4 days.

CONCLUSIONS

SIC is a clinically relevant complication of sepsis. Although it might be less frequent than previously reported, its occurrence is associated with higher morbidity and mortality and should be interpreted as an early warning sign.

Management Strategies in Septic Coagulopathy: A Review of the Current Literature

One of the 'organs' that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized.

Serum Thrombomodulin Level Can Predict Mortality in Patients With Sepsis?

Background

Thrombomodulin (TM) is a type-1 trans-membrane glycoprotein on endothelial cells which is known to be involved in various biochemical pathways. TM can be detected in biological fluids such as blood and urine under many forms. Soluble thrombomodulin (sTM), consist of various particles of TM, is the predominant agent which is created by enzymatic or chemical catalysis of the whole protein under divergent conditions. TM plays a vital role in protein C system and is crucial in the pathogenesis of Sepsis.

Objective

To identify the serum level of soluble thrombomodulin (sTM) in groups of patients: sepsis and septic shock including their survival and fatal in-hospital outcome; and validate the death prediction of serum sTM in patients with sepsis.

Methods

This prospective observational study was conducted in 63 patients who were diagnosed with sepsis, septic shock according to Sepsis 3 criteria at the ICU Department of Hue Central Hospital, Vietnam, from 3/2022 to 3/2023.

Results

Twenty participants developed septic shock (31.7%), morality within 28-days was 19 patients (30.2%), 22 patients complicated with acute kidney injury that necessitated renal replacement therapy (34.9%), 30 patients required mechanical ventilation (47.6%), the median length of ICU stay was 8 (3-28) days. Serum level of lactate and creatinine were significantly higher in septic shock group compared with sepsis and survival group (p<0.05). The median sTM level in septic shock group and fatal group were 4.68(3.38-6.46) ng/mL and 4.68 (1.69-6.46) ng/mL, respectively. These results were significantly higher than sepsis group [3.62 (1.51-1.94) ng/mL] and survival group [3.73 (1.51-5.9) ng/mL] (p<0.05). The death predictive power of DIC score, APACHE II score, creatinine, sTM and SOFA presented with AUC values of 0.723, 0.726, 0.777, 0.803 and 0.807, respectively. There were no significant difference of serum level IL-6 and PCT between survival and fatal group. The median DIC score in fatal group was 7 (3-7), which was significantly higher than survival group 4 (2-7) (p= 0.001).

Conclusion

Sepsis is a common diagnosis among ICU settings which links the critically ill patients to higher complications and mortalities. Serum level of sTM in septic shock and fatal groups were significantly higher than sepsis and survival groups. sTM is a reliable marker and should be used in predict severity and mortality in sepsis patients.

Communication from the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis on sepsis-induced coagulopathy in the management of sepsis

Disseminated intravascular coagulation (DIC) is a life-threatening complication in sepsis and other critical conditions. The International Society on Thrombosis and Haemostasis (ISTH) released the diagnostic criteria for overt DIC in 2001. Since then, ISTH overt DIC has been used as the global standard criterion for a decompensated stage of DIC. Because detecting an earlier stage of DIC would be useful for therapeutic considerations, the scientific standardization committees of the ISTH introduced the sepsis-induced coagulopathy (SIC) scoring system in 2019. The SIC scoring system is specifically designed to detect the compensated phase of DIC in sepsis, which can lead to overt DIC with disease progression. Studies examining the performance of the SIC scoring system have reported its usefulness over the past 5 years. The reported incidence of SIC was approximately 60% in patients with sepsis, which was twice as much as that of overt DIC. Almost all patients with overt DIC were diagnosed with SIC earlier. The reported mortality of SIC was ≥30% and, thus, can be used for patient selection for anticoagulant therapy. Despite the limited data, some continue to suggest the potential efficacy of anticoagulant therapy in patients with SIC. Although heparin, antithrombin, and thrombomodulin are the candidates for anticoagulation, none of them have proven to be effective with robust evidence, and future trials are warranted.

Prognostic Accuracy of the Different Scoring Systems for Assessing Coagulopathy in Sepsis: A Retrospective Study

There is no gold standard for the diagnosis of coagulation dysfunction in sepsis, and the use of the current scoring systems is still controversial. The purpose of this study was to assess the performance of sepsis-induced coagulopathy (SIC), the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), and the International Society on Thrombosis and Haemostasis overt DIC (ISTH overt-DIC). The relationship between each scoring system and 28-day all-cause mortality was examined. Among 452 patients (mean age, 65 [48,76] years), 306 [66.7%] were men, the median SOFA score was 6 [4,9], and the median APACHE II score was 15 [11,22]. A total of 132 patients (29.2%) died within 28 days. Both the diagnosis of SIC (AUROC, 0.779 [95% CI, 0.728-0.830], P < 0.001) and ISTH overt-DIC (AUROC, 0.782 [95% CI, 0.732-0.833], P < 0.001) performed equally well in the discrimination of 28-day all-cause mortality (between-group difference: SIC versus ISTH overt-DIC, -0.003 [95% CI, -0.025-0.018], P = 0.766). However, the SIC demonstrated greater calibration for 28-day all-cause mortality than ISTH overt-DIC (the coincidence of the calibration curve of the former is higher than that of the latter). The diagnosis of JAAM DIC was not independently associated with 28-day all-cause mortality in sepsis (RR, 1.115, [95% CI 0.660-1.182], P = 0.684). The SIC scoring system demonstrated superior prognostic prediction ability in comparison with the others and is the most appropriate standard for diagnosing coagulopathy in sepsis.

Disseminated Intravascular Coagulation in Sepsis and Associated Factors

Background: sepsis is a life-threatening organ dysfunction caused by an excessive host immunological response to infection. The incidence of sepsis is increasing every year, and sepsis is the primary cause of mortality in intensive care units (ICUs). DIC is a coagulopathy syndrome that causes microvascular and macrovascular thrombosis and increases the risk of bleeding due to consumptive coagulopathy. The pathophysiology of DIC in sepsis is complex, and further research is required to investigate the involved mechanisms and risk factors. Method: this study is a prognostic analysis of a retrospective cohort. Samples were patients diagnosed with sepsis and admitted to Cipto Mangunkusumo National General Hospital from January 2016 to October 2022. Research subjects were followed until occurrence of DIC during sepsis or recovery from sepsis. The research subjects were selected from medical records using a consecutive total sampling approach. The inclusion criteria were patients aged ≥18 years old and diagnosed with sepsis according to qSOFA criteria with a score of 2. The exclusion criterion was an incomplete medical record. Bivariate and multivariate logistic regression analyses were performed to determine which independent variables contributed to the incidence of DIC and obtain the odds ratios (ORs). p < 0.05 was considered to indicate a statistically significant difference. Results: a total of 248 patients were included after considering the inclusion and exclusion criteria. Of these, 50 (20.2%) septic patients developed DIC. In the multivariate analysis, albumin ≤2.5 g/dL (OR: 2.363; 95% CI: 1.201−4.649), respiratory infection (OR: 2.414; 95% CI: 1.046−5.571), and antibiotic treatment ≥1 h (OR: 2.181; 95% CI: 1.014−4.689) were associated with DIC development. On the basis of the ROC curve, the area under the curve (AUC) was determined to be 0.705 with 95% CI = (0.631−0.778). Conclusion: in our study, the prevalence of DIC in septic patients was 20.2%. Low albumin, respiratory infection, and antibiotic treatment ≥1 h were found to be risk factors for development of DIC in septic patients.

Validation of Two Revised, Simplified Criteria for Assessing Sepsis-Associated Disseminated Intravascular Coagulation in ICU Patients with Sepsis-3: A Retrospective Study

Objective

This study aimed to validate the performance of modified Japanese Association for Acute Medicine (m-JAAM) and simplified Japanese Society on Thrombosis and Hemostasis (s-JSTH) criteria in diagnosing coagulation disorders in sepsis and examine their prognostic value compared with sepsis-induced coagulopathy (SIC) and International Society on Thrombosis and Hemostasis (ISTH) criteria.

Methods

This retrospective study included subjects diagnosed with sepsis (August 2020 to February 2021, n = 296). The m-JAAM, s-JSTH, SIC, and ISTH criteria were evaluated and compared using receiver operating characteristic (ROC) curves and areas under the curve (AUCs).

Results

There was no significant difference in AUC for predicting in-hospital 28-day mortality by m-JAAM, s-JSTH, SCI, and ISTH criteria (0.745, 0.763, 0.760, and 0.730, respectively). The proportion of patients fulfilling the m-JAAM and SIC criteria was higher than that of the s-JSTH and ISTH criteria (43.2%, 56.1% vs. 25.0%, 22.6%, P &lt; .05).

Conclusion

The m-JAAM criteria might be more suitable for early-stage disseminated intravascular coagulation of sepsis than s-JSTH criteria.

A retrospective cohort study on the association between early coagulation disorder and short-term all-cause mortality of critically ill patients with congestive heart failure

Purpose

Coagulation disorder in congestive heart failure (CHF) has been well-documented. The prognostic value of a composite coagulation disorder score, which combines the absolute platelet count, international normalized ratio (INR), and activated partial thromboplastin time (APTT), has not been assessed in CHF. The present study endeavored to explore the association between the coagulation disorder score and adverse outcomes of critically ill patients with CHF.

Methods

Patients diagnosed with CHF in the Medical Information Mart for Intensive Care III (MIMIC-III) database were included in the present retrospective cohort study. The coagulation disorder score was calculated according to the abnormalities of the absolute platelet count, INR, and APTT within 24 h after intensive care unit admission. The primary outcomes were the short-term all-cause mortality, including 30-, 90-day and in-hospital mortalities. The Kaplan-Meier (K-M) survival curve and the Cox proportional hazard model were performed to assess the correlation between coagulation disorder score and outcome events.

Results

A total of 6,895 patients were enrolled in this study and divided into four groups according to the coagulation disorder score. K-M survival curve preliminarily indicated that subjects with higher coagulation disorder score presented lower survival rate and shorter survival time. After adjustment for potential confounders, the multivariate Cox analysis further illustrated that elevated coagulation disorder score as a quartile variable was significantly associated with increased all-cause mortality (quartile 4 vs. quartile 1, 30-day: HR [95% CI], 1.98 [1.50, 2.62], 90-day: HR [95% CI], 1.88 [1.49, 2.37], in-hospital: HR [95%CI], 1.93 [1.42, 2.61]).

Conclusion

In critically ill patients with CHF, ones with high coagulation disorder score tend to be worse clinical prognosis, which would be a promising biomarker and helpful for the management of CHF patients.

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

Background Coagulation abnormalities are common in acute leukemia (AL) and disseminated intravascular coagulation (DIC) frequently complicates the onset of AL.

Aim To determine the prevalence of overt DIC in AL using the International Society on Thrombosis and Haemostasis (ISTH) scoring system.

Materials and Methods This prospective observational study was performed on 57 newly diagnosed or relapsed cases of AL. Detailed clinical history and coagulation profile of the patients were evaluated. Diagnosis of overt and nonovert DIC was established using the ISTH scoring system and results tabulated.

Observations A total of 57 patients with AL participated in the study, including 31 (54.39%) patients with acute lymphoblastic leukemia (ALL) and 26 (45.61%) with acute myeloid leukemia (AML). In total, 18 of 57 patients (31.58%) with AL fulfilled the criteria of overt DIC according to the ISTH scoring system, including 10 (32.25%) patients with ALL and 8 (30.76%) patients with AML. The highest prevalence of DIC was seen in the M3 subtype among AML and the L1 subtype among ALL, respectively. The mean ISTH score in patients of overt DIC in ALL and AML patients was 5.1 and 5, respectively. Abnormalities in platelet count and D-dimer levels were the most useful parameters in diagnosing overt DIC and the difference between overt DIC and nonovert DIC groups was highly significant.

Conclusions Overt DIC was observed in approximately one-third of patients with AL. Prevalence of overt DIC was found to be comparable in patients with ALL and AML. Mean platelet count and D-dimer levels were the most useful parameters in detecting overt DIC.

How to recognize and manage COVID-19-associated coagulopathy

COVID-19 is frequently associated with abnormalities on coagulation testing and a coagulopathy driven by inflammation, intravascular coagulation activation, and microvascular thrombosis. Elevated D-dimer is the most common finding and is a predictor of adverse outcomes including thrombosis, critical illness, and death. Although COVID-19-associated coagulopathy has some similarities to disseminated intravascular coagulation, the platelet count is usually preserved, coagulation times are usually normal or minimally prolonged, and thrombosis is more common than bleeding, at least in noncritically ill patients. Bleeding is uncommon but may be a significant problem in critically ill patients, including those who may develop a consumptive coagulopathy with frank disseminated intravascular coagulation and those on extracorporeal membrane oxygenation. Blood product support to correct coagulopathy is reserved for bleeding patients or those requiring invasive procedures. Current recommendations suggest that all hospitalized patients should receive at least a prophylactic dose of anticoagulation. Results from a multiplatform randomized clinical trial suggest that therapeutically dosed anticoagulation may improve outcomes, including the need for organ support and mortality in moderately ill patients but not in those requiring critical care. The results of ongoing trials evaluating the impact of different antithrombotic strategies (therapeutic agents and intensity) on COVID-19 outcomes are eagerly awaited and are expected to have important implications for patient management. We also discuss COVID-19 vaccine-associated cytopenias and bleeding as well as vaccine-induced thrombotic thrombocytopenia, in which thrombosis is associated with thrombocytopenia, elevated D-dimer, and, frequently, hypofibrinogenemia.

Hypercoagulability of COVID-19 and Neurological Complications: A Review

The SARS-CoV-2 virus, which causes Coronavirus disease 2019 (COVID-19), has resulted in millions of worldwide deaths. When the SARS-CoV-2 virus emerged from Wuhan, China in December 2019, reports of patients with COVID-19 revealed that hospitalized patients had acute changes in mental status, cognition, and encephalopathy. Neurologic complications can be a consequence from overall severity of the systemic infection, direct viral invasion of the SARS-CoV-2 virus in the central nervous system, and possible immune mediated mechanisms. We will examine the landscape regarding this topic in this review in addition to current understandings of COVID-19 and hemostasis, treatment, and prevention, as well as vaccination.

Validation of sepsis-induced coagulopathy score in critically ill patients with septic shock: post hoc analysis of a nationwide multicenter observational study in Japan

Coagulation disorder is a major cause of death in sepsis patients. Recently, sepsis-induced coagulopathy (SIC) scoring was developed as a new criterion for coagulopathy-associated sepsis. We aimed to evaluate the accuracy of the SIC score for predicting the prognosis of septic shock. We analyzed data from a multicenter observational study conducted from 2011 to 2013. We grouped the participants into those who did and did not use vasopressors, and compared the in-hospital mortality rates of SIC and non-SIC patients. Patients who needed vasopressors were considered to have septic shock. We performed survival analysis adjusted by factors independently associated with mortality. SIC developed in 66.4% of patients who used vasopressors and 42.2% of patients who did not. The in-hospital mortality difference between the SIC and non-SIC groups was statistically significant in those who needed vasopressors (35.8% vs 27.9%, p < 0.01). Cox regression analysis indicated that SIC was significantly correlated with mortality risk in patients who used vasopressors (hazard ratio [HR] 1.39; 95% confidence interval [CI] 1.13-1.70; p < 0.01), but not in those who did not (HR 1.38; 95% CI 0.81-2.34; p = 0.23). In conclusion, the SIC score might be a good diagnostic indicator of fatal coagulopathy among sepsis patients who need vasopressors.

Understanding COVID-19-associated coagulopathy: From PIC to SIC or DIC

Coagulopathy, characterized by a high D-dimer level, is a common pathological occurrence in coronavirus disease 2019 (COVID-19) and is associated with poor prognosis. Severe cases with COVID-19 is associated with a significantly higher risk of deep vein thrombosis and acute pulmonary embolism. Pulmonary intravascular coagulopathy is the characteristic coagulopathy in COVID-19. Unlike sepsis-induced coagulopathy and disseminated intravascular coagulation, which are manifestations of systemic coagulopathy, pulmonary intravascular coagulopathy is a manifestation of a local coagulation disorder in the lung. The progression from pulmonary intravascular coagulopathy to sepsis-induced coagulopathy or disseminated intravascular coagulation in the context of COVID-19 may indicate that the patient's coagulation dysfunction has progressed from local to systemic. Exploring the associated coagulation disease will aid in the understanding of the pathophysiological mechanisms underlying severe COVID-19.

Coagulopathy and sepsis: Pathophysiology, clinical manifestations and treatment

Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a known predictor of worse prognosis during sepsis. The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased platelet production, platelet sequestration and increased consumption. DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be resolved with treatment of the underlying disorder, which is considered the cornerstone in the management of this syndrome. This review presents the current knowledge on the pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.

The Value of Thromboelastography in the Diagnosis of Sepsis-Induced Coagulopathy

Thromboelastography (TEG) is regularly used for monitoring abnormalities of the coagulation system in patients with sepsis. However, it is unclear whether TEG parameters are associated with sepsis-induced coagulopathy (SIC). Thus, we aimed to assess the diagnostic value of TEG for SIC. The medical records of patients who underwent TEG from January 2016 to December 2016 were analyzed retrospectively. The patients were divided into sepsis group and non-sepsis group. Baseline patient characteristics and coagulation function indexes were compared. Receiver–operating characteristic curve analysis was used to determine predictors of SIC. A total of 167 patients were included, of whom 84 had sepsis. The clot formation speed (K) was significantly higher(P < 0.001), and the maximum amplitude (MA) and angle were significantly lower (both P < 0.001) in the sepsis group than that in non-sepsis group. Patients with SIC had higher Sepsis-related Organ Failure Assessment scores than those patients without SIC (P < 0.001). The area under the curve of K for diagnosing SIC was 0.910. The area under the curve of angle and MA for excluding SIC was 0.895 and 0.882, respectively. Thus, TEG parameters have good diagnostic value for SIC.

Acute Viral Illnesses and Ischemic Stroke: Pathophysiological Considerations in the Era of the COVID-19 Pandemic

The severe acute respiratory syndrome coronavirus 2 or coronavirus disease 2019 (COVID-19) pandemic has raised concerns about the correlation with this viral illness and increased risk of stroke. Although it is too early in the pandemic to know the strength of the association between COVID-19 and stroke, it is an opportune time to review the relationship between acute viral illnesses and stroke. Here, we summarize pathophysiological principles and available literature to guide understanding of how viruses may contribute to ischemic stroke. After a review of inflammatory mechanisms, we summarize relevant pathophysiological principles of vasculopathy, hypercoagulability, and hemodynamic instability. We will end by discussing mechanisms by which several well-known viruses may cause stroke in an effort to inform our understanding of the relationship between COVID-19 and stroke.

Neuroimaging Findings of Hospitalized Covid-19 Patients: A Canadian Retrospective Observational Study

PURPOSE

Coronavirus disease (COVID-19) has been associated with neurologic sequelae and neuroimaging abnormalities in several case series previously. In this study, the neuroimaging findings and clinical course of adult patients admitted with COVID-19 to a tertiary care hospital network in Canada were characterized.

METHODS

This is a retrospective observational study conducted at a tertiary hospital network in Ontario, Canada. All adult patients with PCR-confirmed COVID-19 admitted from February 1, 2020 to July 22, 2020 who received neuroimaging related to their COVID-19 admission were included. CT and MR images were reviewed and categorized by fellowship-trained neuroradiologists. Demographic and clinical data were collected and correlated with imaging findings.

RESULTS

We identified 422 patients admitted with COVID-19 during the study period. 103 (24.4%) met the inclusion criteria and were included: 30 ICU patients (29.1%) and 73 non-ICU patients (70.9%). A total of 198 neuroimaging studies were performed: 177 CTs and 21 MRIs. 17 out of 103 imaged patients (16.8%) had acute abnormalities on neuroimaging: 10 had macrohemorrhages (58.8%), 9 had acute ischemia (52.9%), 4 had SWI abnormalities (23.5%), and 1 had asymmetric sulcal effacement suggesting possible focal encephalitis (5.8%). ICU patients were more likely to have positive neuroimaging findings, more specifically acute ischemia and macrohemorrhages (P < 0.05). Macrohemorrhages were associated with increased mortality (P < 0.05).

CONCLUSION

Macrohemorrhages, acute ischemia and SWI abnormalities were the main neuroimaging abnormalities in our cohort of hospitalized COVID-19 patients. Acute ischemia and hemorrhage were associated with worse clinical status.

Development of a Nomogram to Predict 28-Day Mortality of Patients With Sepsis-Induced Coagulopathy: An Analysis of the MIMIC-III Database

Background: Sepsis-induced coagulopathy (SIC) is a common cause for inducing poor prognosis of critically ill patients in intensive care unit (ICU). However, currently there are no tools specifically designed for assessing short-term mortality in SIC patients. This study aimed to develop a practical nomogram to predict the risk of 28-day mortality in SIC patients.

Methods: In this retrospective cohort study, we extracted patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Sepsis was defined based on Sepsis 3.0 criteria and SIC based on Toshiaki Iba's criteria. Kaplan–Meier curves were plotted to compare the short survival time between SIC and non-SIC patients. Afterward, only SIC cohort was randomly divided into training or validation set. We employed univariate logistic regression and stepwise multivariate analysis to select predictive features. The proposed nomogram was developed based on multivariate logistic regression model, and the discrimination and calibration were verified by internal validation. We then compared model discrimination with other traditional severity scores and machine learning models.

Results: 9432 sepsis patients in MIMIC III were enrolled, in which 3280 (34.8%) patients were diagnosed as SIC during the first ICU admission. SIC was independently associated with the 7- and 28-day mortality of ICU patients. K–M curve indicated a significant difference in 7-day (Log-Rank: P < 0.001 and P = 0.017) and 28-day survival (Log-Rank: P < 0.001 and P < 0.001) between SIC and non-SIC groups whether the propensity score match (PSM) was balanced or not. For nomogram development, a total of thirteen variables of 3,280 SIC patients were enrolled. When predicted the risk of 28-day mortality, the nomogram performed a good discrimination in training and validation sets (AUROC: 0.78 and 0.81). The AUROC values were 0.80, 0.81, 0.71, 0.70, 0.74, and 0.60 for random forest, support vector machine, sequential organ failure assessment (SOFA) score, logistic organ dysfunction score (LODS), simplified acute physiology II score (SAPS II) and SIC score, respectively, in validation set. And the nomogram calibration slope was 0.91, the Brier value was 0.15. As presented by the decision curve analyses, the nomogram always obtained more net benefit when compared with other severity scores.

Conclusions: SIC is independently related to the short-term mortality of ICU patients. The nomogram achieved an optimal prediction of 28-day mortality in SIC patient, which can lead to a better prognostics assessment. However, the discriminative ability of the nomogram requires validation in external cohorts to further improve generalizability.

Biomarkers of Platelet Activation and Their Prognostic Value in Patients With Sepsis-Associated Disseminated Intravascular Coagulopathy

Sepsis-associated disseminated intravascular coagulation (DIC) is related to marked hemostatic changes such as transient thrombocytopenia secondary to the endogenous activation and consumption of platelets. This study measured markers of platelet function in 103 adult ICU patients with clinically established sepsis-associated DIC to determine the biomarker association with disease severity. Patients were categorized as having no DIC, nonovert DIC, or overt DIC using the International Society of Thrombosis and Hemostasis scoring system. Plasma levels of CD40L, platelet factor 4 (PF4), platelet-derived microparticles, and microparticle-associated tissue factor were quantified. Markers of platelet activation were significantly elevated in patients with DIC compared to healthy individuals. This increase was independent of platelet count. Levels of PF4 differed based on the severity of DIC and differentiated nonsurvivors and survivors. These findings suggest that the markers of platelet activation in DIC may not be regulated by the number of circulating platelets and may be independent of the factors leading to their consumption.

An audit of disseminated intravascular coagulation screen requests at an academic hospital laboratory in central South Africa

INTRODUCTION

Disseminated intravascular coagulation (DIC) is a feared complication of various systemic illnesses. We aimed to evaluate the laboratory requesting practices of clinicians, especially concerning the laboratory parameters, included in the International Society of Thrombosis and Haemostasis (ISTH) DIC score.

METHODS

A retrospective descriptive study was performed and included data from DIC screen requests analysed at Universitas National Health Laboratory Service (NHLS) laboratory, Bloemfontein, South Africa, for one calendar year. Laboratory request forms were analysed, recording the pretest diagnosis and whether the diagnosis was associated with DIC. Parameters of the DIC screen, prothrombin time, activated partial thromboplastin time, thrombin time, d-dimer and fibrinogen were used to calculate the ITSH DIC score and diagnose heparin contamination. The platelet count, currently not part of the DIC screen test set, was also recorded.

RESULTS

A total of 778 DIC screen requests were processed. One hundred and eighty-three requests were excluded due to laboratory-defined rejection criteria, heparin contamination or for lacking an ISTH score parameter. Of the remaining 595 complete requests, 283 (47.7%) were laboratory-defined overt DIC. The pretest diagnosis was not predictive of either a positive or negative finding of overt DIC. The contribution of fibrinogen to assigning overt DIC was questionable.

CONCLUSION

The number of DIC screen requests received highlights the need for laboratory evidence of DIC. To improve laboratory DIC testing, the authors suggest critical evaluation of the contribution of the pretest diagnosis and fibrinogen in a prospective study and adding the platelet count in our local DIC test set.

Recent advances in the research and management of sepsis-associated DIC

Disseminated intravascular coagulation (DIC) is a common and life-threatening complication in sepsis. Sepsis-associated DIC is recognized as the systemic activation in coagulation with suppressed fibrinolysis that leads to organ dysfunction in combination with systemic intravascular inflammation. In this process, thrombin contributes a key role in connecting both coagulation and inflammation. Endothelial injury, a result of sepsis, causes DIC due to the effect of multiple activated factors that include neutrophils, platelets, and damage-associated molecular patterns. Recent advances in the understanding of pathophysiology have made it possible to diagnose sepsis-associated DIC at earlier timing with better accuracy. However, progress in the treatment is still limited, and new therapeutics for sepsis-associated DIC are needed.

Hypocoagulable Tendency on Thromboelastometry Associated With Severity and Anticoagulation Timing in Pediatric Septic Shock: A Prospective Observational Study

Objective: To identify whether coagulation profiles using thromboelastometry are associated with outcomes in pediatric septic shock. The primary outcomes were the development of disseminated intravascular coagulation (DIC) and the severity of the pediatric intensive care unit (PICU) existing scoring systems, while the secondary outcome was hospital mortality. This study aimed to contribute to current findings of the limitations of conventional tests in determining the optimal timing of anticoagulation in sepsis. Design: A prospective, observational study conducted between August 2019 and August 2020. Setting: PICU at a pediatric tertiary hospital in Hanoi, Vietnam. Patients: Fifty-five pediatric patients who met the septic shock criteria were enrolled. Measurements and Main Results: Fifty-five patients with septic shock were recruited. At the time of diagnosis, thromboelastometry revealed normocoagulability, hypercoagulability, and hypocoagulability in 29, 29, and 42% of the patients, respectively (p > 0.05); however, most patients in the overt DIC and non-survival groups progressed to hypocoagulability (82 and 64%, respectively). The overt DIC, PELOD-2 > 8, PRISM-III > 11, and non-survival group had a significant hypocoagulable tendency according to thromboelastometry parameters [prolonged clotting time (CT) and clot formation time (CFT); and reduced α-angle (α), maximum clot firmness (MCF), thrombodynamic potential index (TPI)] compared to the non-overt DIC, PELOD-2 ≤ 8, PRISM-III score ≤ 11 and survival group (p < 0.05). Conventional parameters between the normocoagulable and hypercoagulable groups were not different (p > 0.05). Hypocoagulability was characterized by lower platelet count and fibrinogen level, higher prolonged prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), and higher D-dimer level than in hypercoagulability (p < 0.05). Hypocoagulable tendency on thromboelastometry had a higher hazard at a PT > 16.1 s [area under the curve (AUC) = 0.747, odds ratio (OR) = 10.5, p = 0.002], INR > 1.4 (AUC = 0.754, OR = 6.9, p = 0.001), fibrinogen <3.3 g/L (AUC = 0.728, OR = 9.9, p = 0.004), and D-dimer > 3,863 ng/mL (AUC = 0.728, OR = 6.7, p = 0.004). Conclusions: Hypocoagulable tendency using thromboelastometry is associated with the severity of septic shock. Conventional coagulation tests may fail to detect hypercoagulability, which is crucial in determining anticoagulation timing.

Predictors and outcomes of healthcare-associated infections in COVID-19 patients

Introduction

Healthcare-associated infections (HAI) after viral illnesses are important sources of morbidity and mortality. This has not been extensively studied in hospitalized COVID-19 patients.

Methods

This study included all COVID-19-positive adult patients (≥18 years) hospitalized between 01 March and 05 August 2020 at the current institution. The Centers for Disease Control and Prevention definition of HAI in the acute care setting was used. The outcomes that were studied were rates and types of infections and in-hospital mortality. Several multivariable logistic regression models were constructed to examine characteristics associated with development of HAI.

Results

Fifty-nine (3.7%) of 1565 patients developed 140 separate HAIs from 73 different organisms: 23 were Gram-positive, 39 were Gram-negative and 11 were fungal. Patients who developed HAI did not have higher odds of death (OR 0.85, 95% CI 0.40–1.81, p =  0.69). HAIs were associated with the use of tocilizumab (OR 5.04, 95% CI 2.4–10.6, p <  0.001), steroids (OR 3.8, 95% CI 1.4–10, p =  0.007), hydroxychloroquine (OR 3.0, 95% CI 1.0–8.8, p =  0.05), and acute kidney injury requiring hemodialysis (OR 3.7, 95% CI 1.1–12.8, p =  0.04).

Conclusions

HAI were common in hospitalized Covid-19 patients. Tocilizumab and steroids were associated with increased risk of HAIs.

Disseminated intravascular coagulation: A devastating systemic disorder of special concern with COVID-19

Disseminated intravascular coagulation (DIC) is linked with severe COVID-19, prompting considerable concern. DIC can be a devastating systemic disorder. It is often markedly manifest on the skin as acrocyanosis or as petechiae and purpura with progression to hemorrhagic bullae. Subcutaneous hematomas may occur, as may thrombotic findings including necrosis and gangrene. The most common cause is infection, with special emphasis now on COVID-19. We have reviewed the medical literature under the search terms "Disseminated intravascular coagulation" and "consumption coagulopathy" for the past two decades in the English language using Medline and Google Scholar to update special concerns and considerations, focusing on those with COVID-19. Skin findings with DIC may be prominent. The severity of cutaneous lesions often correlates with the gravity of systemic disease. DIC is most effectively treated by addressing the underlying cause and resuscitating the patient using supportive measures. It is pivotal to recognize and treat DIC early, before deadly complications, such as multiple organ failure, arise.

Evaluation of Sepsis-Induced Coagulopathy in Critically Ill Pediatric Patients with Septic Shock

BACKGROUND

 Coagulopathy is a common serious complication of sepsis and septic shock; thus, its early detection and prompt management are important. For this purpose, recently the sepsis-induced coagulopathy (SIC) score was proposed.

METHODS

 We modified the SIC score for critically ill children with septic shock and evaluated its performance in comparison to several coagulopathy diagnostic scoring systems.

RESULTS

 Among 135 included patients, a significant number of patients were diagnosed with coagulopathy using different coagulopathy diagnostic criteria (up to 84.4% using the SIC score). The modified SIC score, comprising the pediatric sequential organ failure assessment (pSOFA) score, prothrombin time, and D-dimer, was used to diagnose SIC in 68 (50.4%) patients. It was well correlated with the pSOFA score and the International Society on Thrombosis and Haemostasis disseminated intravascular coagulation (DIC) score, as well as the SIC score (p < 0.001). The overall 28-day mortality rate was 18.7%. Patients with coagulopathy had worse clinical outcomes compared to those without coagulopathy. The modified SIC score was identified as an independent prognostic factor for 28-day mortality. The area under the receiver operating characteristic curve for performance of the modified SIC score to predict 28-day mortality evaluated was 0.771 (95% confidence interval: 0.658-0.883), better than those of the SIC and ISTH DIC scores (p < 0.05).

CONCLUSION

 Critically ill pediatric patients with septic shock frequently had concomitant coagulopathy. The modified SIC score showed good ability to predict 28-day mortality, suggesting its potential as a prognostic factor in these critically ill pediatric patients.

Alteraciones hematológicas en COVID-19

 El SARS (síndrome respiratorio agudo grave) es el estadio grave de la COVID-19 ocasionado por el SARS-CoV-2, que causa infecciones respiratorias en humanos y cuya transmisión se da principalmente por contacto. El virus ingresa a la célula huésped por la interacción de la proteína S con la enzima convertidora de angiotensina II (ACE2), presente en el tracto respiratorio, así como en monocitos, macrófagos, células endoteliales, corazón y tracto gastrointestinal. El aumento de IFN frena la replicación viral y activa la respuesta inmune adaptativa. Así, las manifestaciones clínicas de la infección se presentan frecuentemente a nivel del tracto respiratorio; sin embargo, también pueden involucrar otros sistemas como el hematopoyético. En el hemograma se observan recuentos celulares alterados, principalmente leucocitos y plaquetas. La linfopenia y neutrofilia se asocian con enfermedad severa y la trombocitopenia se presenta de manera heterogénea en la infección. Entre las complicaciones se encuentra la coagulación intravascular diseminada, producida cuando los monocitos y las células endoteliales son activadas por la liberación de citoquinas; esto genera daño endotelial, con la síntesis del factor tisular, secreción de factor tisular, activación plaquetaria y liberación del factor Von Willebrand, así como una condición hiperfibrinolítica especialmente en estadios tardíos de la infección. Las pruebas de laboratorio como el dímero D, los productos de degradación de la fibrina (PDF), tiempo de protrombina (TP), tiempo de tromboplastina parcial activado (TTPA), entre otras, son fundamentales para el diagnóstico, seguimiento y pronóstico de la enfermedad.

Neuroimaging Findings in Patients with COVID-19

Little is known about the neurologic sequelae of coronavirus disease 2019 (COVID-19). We assessed neuroimaging findings in 4 patients positive for COVID-19. All had abnormal mental status, deranged coagulation parameters, and markedly elevated D-dimer levels. CT/MR imaging showed a common pattern of multifocal subcortical/cortical petechial-type hemorrhages, while SWI showed more extensive multifocal abnormalities. The appearances are consistent with a thrombotic microangiopathy and may be due to the heightened level of thrombosis in patients with COVID-19.

Performances of disseminated intravascular coagulation scoring systems in septic shock patients

BACKGROUND

There is no gold standard to diagnose septic shock-induced disseminated intravascular coagulation (DIC). The objective of our multicenter prospective study was to assess the performances of the different major scoring systems in terms of mortality prediction and DIC diagnosis. The JAAM-DIC 2016 score, the ISTH overt-DIC 2001 score, the associations of sepsis-induced coagulopathy (SIC) score with JAAM-DIC 2016 or ISTH overt-DIC scores were tested in patients within 12 h of their admission in ICU for septic shock (day 1) and at day 2.

RESULTS

582 patients were enrolled in the study. 182/567 (32.1%) were diagnosed with DIC according to ISTH overt-DIC score, and 193/561 (34.4%) according to JAAM-DIC score; 486/577 patients (84.2%) were diagnosed with a coagulopathy according to SIC score. A moderate concordance was observed between ISTH overt-DIC and JAAM-DIC [κ = 0.67 (0.60, 0.73), p < 0.001]. The delay of positivity of the scores for early DIC patients was not different between JAAM-DIC and ISTH overt-DIC scores. Although it was positive earlier, SIC score had worse diagnosis specificity, as 84.2% of the patients with septic shock were diagnosed with "coagulopathy". The specificity of SIC score alone to predict mortality was very low [0.18 (0.15; 0.22)], compared to the ones of JAAM-DIC score [0.71 (0.67; 0.75)], and of ISTH overt-DIC score [0.76 (0.72; 0.80)], p < 0.001. The sensitivity of SIC score to predict mortality was 0.95 [0.89; 0.98], and the ones of JAAM-DIC score and ISTH overt-DIC score were 0.61 [0.50; 0.70] and 0.68 [0.58; 0.77], respectively. There was no benefit in sensitivity and specificity in combining SIC score to JAAM-DIC score or to ISTH overt-DIC score, compared to JAAM-DIC score or ISTH overt-DIC score alone.

CONCLUSIONS

Our data suggest that the added value of SIC score alone or combined with other scores is limited, and that both JAAM-DIC score and ISTH overt-DIC score can be used in septic shock patients. Trial registration clinicaltrial; Trial registration number: NCT02391792; Date of registration: 18/03/2015; URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT02391792?term=meziani&draw=4&rank=1.

iTRAQ-based quantitative proteomic analysis of the therapeutic effects of 2% hydrogen gas inhalation on brain injury in septic mice

Sepsis encephalopathy (SAE) has a high incidence and mortality rate in patients with sepsis; however, there is currently no effective treatment. Our previous studies have reported that 2% hydrogen (H₂) gas inhalation had a protective effect on sepsis and SAE; however, the specific mechanism have not been fully elucidated. In the current study, male Institute of Cancer Research mice were either used to create the cecal ligation and puncture (CLP) model or for sham surgery, followed by 2% H₂ gas inhalation for 60 min beginning at 1 and 6 h following sham or CLP surgeries. The isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics combined with liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis, hematoxylin and eosin (H&E) staining, Nissl staining, and western blot analysis were used to investigate the effects of H₂ on brain injury in mice with sepsis. The results of the H&E, and Nissl staining indicated that the CLP mice had a significant brain injury, which was characterized by aggravated pathological damage and was alleviated by 2% H₂ inhalation. Quantitative proteomics based on iTRAQ combined with LC-MS/MS analysis quantified a total of 5317 proteins, of which 39 were connected with the protective mechanism of H₂. In addition, H₂ could regulate the immune and the coagulation systems. Furthermore, western blot analysis revealed that H₂ decreased SAE in septic mice by downregulating the protein expression levels of SMAD4, DPYS, PTGDS and upregulating the expression level of CUL4A. These results provide insights into the mechanism of the positive effect of H₂ on SAE and contribute to the clinical application of H₂ in patients with sepsis.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Flow Cytometry-Based Quantification of Neutrophil Extracellular Traps Shows an Association with Hypercoagulation in Septic Shock and Hypocoagulation in Postsurgical Systemic Inflammation-A Proof-of-Concept Study

This proof-of-concept study aimed to evaluate a novel method of flow cytometry-based quantification of neutrophil extracellular traps (NETs) in septic shock patients and to identify possible interactions between the number of free-circulating NETs and alterations of the coagulatory system. Patients suffering from septic shock, a matched control group (CTRL), and patients suffering from systemic inflammation after cardiac (CABG) or major abdominal surgery (MAS) were enrolled in this prospective proof-of-concept study. Compared to the matched controls, free-circulating NETs were significantly elevated in septic shock and postsurgical patients (data are presented in median (IQR)); septic shock: (2.7 (1.9-3.9); CABG: 2.7 (2.1-3.7); MAS: 2.7 (2.1-3.9); CTRL: 1.6 (1-2); CTRL vs. septic shock: p = 0.001; CTRL vs. CABG: p < 0.001; CTRL vs. MAS: p < 0.001). NETs correlated positively with FIBTEM mean clot firmness (MCF) in septic shock patients (r = 0.37, p < 0.01) while they correlated negatively in surgical patients (CABG: r = -0.28, p < 0.01; MAS: r = -0.25, p = 0.03). Flow-cytometric quantification of NETs showed a significant increase in free-circulating NETs under inflammatory conditions. Furthermore, this study hints to an association of the number of NETs with hypercoagulation in septic shock patients and hypocoagulation in surgery-induced inflammation.