Evaluation of Disseminated Intravascular Coagulation in Critically Ill Pediatric Hemato-oncology Patients with Septic Shock

Abstract

Background Disseminated intravascular coagulation (DIC) is a serious complication in septic shock. This study aimed to evaluate DIC and associated clinical outcomes using the International Society on Thrombosis and Hemostasis (ISTH) and modified ISTH overt DIC scores in critically ill pediatric hemato-oncology patients with septic shock.

Methods Pediatric hemato-oncology patients with septic shock admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital between January 2013 and February 2020 were included. We modified the ISTH overt DIC score by eliminating the platelet domain and compared the performances of the ISTH and the modified ISTH overt DIC scores in DIC diagnosis and PICU mortality prediction of these patients.

Results DIC was diagnosed in 56.4 and 38.5% of patients by ISTH and modified ISTH overt DIC scores, respectively. Patients with DIC showed a higher pediatric risk of mortality (PRISM) III, pediatric sequential organ failure assessment (pSOFA) scores, and PICU mortality than those without DIC (p < 0.05). The modified ISTH overt DIC score was an independent prognostic factor for PICU mortality and showed a larger area under the receiver operating characteristic curve than the ISTH overt DIC score (0.687 vs. 0.695). Addition of the DIC diagnosis improved the performance of PRISM III in predicting PICU mortality.

Conclusion Critically ill pediatric hemato-oncology patients with septic shock frequently experience DIC, which was adequately evaluated by both ISTH and modified ISTH overt DIC scores. Considering the characteristics of these patients, the modified ISTH overt DIC score may be a promising prognostic factor for clinical outcomes in these critically ill pediatric patients.

Keywords

pediatric - disseminated intravascular coagulation - septic shock - intensive care unit

• References

• 1 Tamburro R. Pediatric cancer patients in clinical trials of sepsis: factors that predispose to sepsis and stratify outcome. Pediatr Crit Care Med 2005; 6 (03) S87-S91
• 2 Pound CM, Johnston DL, Armstrong R, Gaboury I, Menon K. The morbidity and mortality of pediatric oncology patients presenting to the intensive care unit with septic shock. Pediatr Blood Cancer 2008; 51 (05) 584-588
• 3 Demaret P, Pettersen G, Hubert P, Teira P, Emeriaud G. The critically-ill pediatric hemato-oncology patient: epidemiology, management, and strategy of transfer to the pediatric intensive care unit. Ann Intensive Care 2012; 2 (01) 14
• 4 Levi M, Sivapalaratnam S. Disseminated intravascular coagulation: an update on pathogenesis and diagnosis. Expert Rev Hematol 2018; 11 (08) 663-672
• 5 Papageorgiou C, Jourdi G, Adjambri E. et al. Disseminated intravascular coagulation: an update on pathogenesis, diagnosis, and therapeutic strategies. Clin Appl Thromb Hemost 2018; 24 (9_suppl): 8S-28S
• 6 Levi M, van der Poll T. Coagulation and sepsis. Thromb Res 2017; 149: 38-44
• 7 Simmons J, Pittet JF. The coagulopathy of acute sepsis. Curr Opin Anaesthesiol 2015; 28 (02) 227-236
• 8 Okamoto K, Tamura T, Sawatsubashi Y. Sepsis and disseminated intravascular coagulation. J Intensive Care 2016; 4: 23
• 9 Zaragoza JJ, Espinoza-Villafuerte MV. Current approach to disseminated intravascular coagulation related to sepsis - organ failure type. World J Hepatol 2017; 6 (01) 11-16
• 10 Singer M, Deutschman CS, Seymour CW. et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 2016; 315 (08) 801-810
• 11 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med 2020; 21 (02) e52-e106
• 12 Gando S, Saitoh D, Ogura H. et al; Japanese Association for Acute Medicine Sepsis Registry Study Group. A multicenter, prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis. Crit Care 2013; 17 (03) R111
• 13 Jhang WK, Ha E, Park SJ. Evaluation of disseminated intravascular coagulation scores in critically ill pediatric patients with septic shock. J Crit Care 2018; 47: 104-108
• 14 Kinasewitz GT, Zein JG, Lee GL, Nazir SA, Taylor Jr FB. Prognostic value of a simple evolving disseminated intravascular coagulation score in patients with severe sepsis. Crit Care Med 2005; 33 (10) 2214-2221
• 15 Asakura H, Takahashi H, Uchiyama T. et al; DIC subcommittee of the Japanese Society on Thrombosis and Hemostasis. Proposal for new diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis. Thromb J 2016; 14: 42
• 16 Taylor Jr FB, Toh CH, Hoots WK, Wada H, Levi M. Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86 (05) 1327-1330
• 17 Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24 (05) 743-752
• 18 Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the Sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171 (10) e172352
• 19 Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6 (01) 2-8
• 20 Gando S, Saitoh D, Ogura H. et al; Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC) Study Group. Disseminated intravascular coagulation (DIC) diagnosed based on the Japanese Association for Acute Medicine criteria is a dependent continuum to overt DIC in patients with sepsis. Thromb Res 2009; 123 (05) 715-718
• 21 Angstwurm MW, Dempfle CE, Spannagl M. 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. Crit Care Med 2006; 34 (02) 314-320
• 22 Di Nisio M, Baudo F, Cosmi B. et al; Italian Society for Thrombosis and Haemostasis. Diagnosis and treatment of disseminated intravascular coagulation: guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2012; 129 (05) e177-e184
• 23 Ha SO, Park SH, Hong SB, Jang S. Performance evaluation of five different disseminated intravascular coagulation (DIC) diagnostic criteria for predicting mortality in patients with complicated sepsis. J Korean Med Sci 2016; 31 (11) 1838-1845
• 24 Wada H, Thachil J, Di Nisio M. et al; The Scientific Standardization Committee on DIC of the International Society on Thrombosis Haemostasis. Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines. J Thromb Haemost 2013;
• 25 Lee DH, Lee BK, Jeung KW. et al. Performance of 5 disseminated intravascular coagulation score systems in predicting mortality in patients with severe trauma. Medicine (Baltimore) 2018; 97 (33) e11912
• 26 Levi M, Ten Cate H. Disseminated intravascular coagulation. N Engl J Med 1999; 341 (08) 586-592
• 27 Iba T, Watanabe E, Umemura Y. et al; Japanese Surviving Sepsis Campaign Guideline Working Group for disseminated intravascular coagulation. Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. J Intensive Care 2019; 7: 32