筛查弥散性血管内凝血本身可能降低脓毒症患者的死亡率：日本全国多中心登记研究。

Screening itself for disseminated intravascular coagulation may reduce mortality in sepsis: A nationwide multicenter registry in Japan.

机构信息

Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.

Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka 558-8558, Japan.

出版信息

Thromb Res. 2018 Jan;161:60-66. doi: 10.1016/j.thromres.2017.11.023. Epub 2017 Nov 26.

DOI:10.1016/j.thromres.2017.11.023

PMID:29202320

Abstract

OBJECTIVES

Screening of patients with sepsis for disseminated intravascular coagulation (DIC) has been recommended in several guidelines. However, DIC screening is still not widely accepted as an essential component of sepsis management, partly because of a lack of evidence that DIC screening has an effect on mortality. We investigated whether DIC screening was associated with a survival benefit in patients with sepsis.

DESIGN

Post hoc analysis of a nationwide multicenter retrospective cohort study.

SETTING

42 intensive care units in Japan.

PARTICIPANTS

2663 adult patients diagnosed as having severe sepsis: 1893 (71.1%) patients were considered candidates for and 770 (28.9%) patients were not considered candidates for International Society of Thrombosis and Hemostasis (ISTH) overt DIC screening on ICU day 1.

MAIN OUTCOME MEASURES

The primary outcome measure was all-cause in-hospital mortality. Patients were stratified according to whether DIC screening was performed at the time of ICU admission (day 1) to investigate the survival effect associated with DIC screening. We also evaluated survival benefit by classifying patients according to whether DIC screening was performed on day 1 and repeated on day 3. Effects of screening on mortality were assessed using Cox proportional hazards models adjusted by the inverse probability of treatment weighting (IPTW) method using propensity scoring.

RESULTS

After adjustment for imbalances, ISTH overt DIC screening on day 1 was associated with significantly lower mortality (IPTW-adjusted HR: 0.836; 95% confidence interval [CI]: 0.711-0.984), and this association became even stronger when ISTH overt DIC screening was repeated on day 3 (IPTW-adjusted HR: 0.727; 95% CI: 0.597-0.884). Besides, we observed an almost comparable effect on mortality associated with DIC screening using the Japanese Association for Acute Medicine criteria.

CONCLUSION

DIC screening was associated with a reduction in mortality in patients with sepsis. This association could be even stronger by repeating DIC screening.

摘要

目的

几项指南均推荐对脓毒症患者进行弥散性血管内凝血（DIC）筛查。然而，DIC 筛查并未广泛被视为脓毒症管理的基本组成部分，部分原因是缺乏证据表明 DIC 筛查对死亡率有影响。我们研究了 DIC 筛查是否与脓毒症患者的生存获益相关。

设计

全国多中心回顾性队列研究的事后分析。

地点

日本 42 个重症监护病房。

参与者

2663 名成年严重脓毒症患者：1893 名（71.1%）患者被认为符合国际血栓与止血学会（ISTH）显性 DIC 筛查标准，770 名（28.9%）患者不符合 ICU 第 1 天 ISTH 显性 DIC 筛查标准。

主要结局指标

全因院内死亡率。根据 ICU 入院时（第 1 天）是否进行 DIC 筛查，对患者进行分层，以研究与 DIC 筛查相关的生存效果。我们还通过分类患者是否在第 1 天和第 3 天进行 DIC 筛查来评估生存获益。采用倾向性评分的逆概率处理权重（IPTW）法调整 Cox 比例风险模型评估筛查对死亡率的影响。

结果

在调整了不平衡因素后，第 1 天进行 ISTH 显性 DIC 筛查与死亡率显著降低相关（IPTW 调整的 HR：0.836；95%置信区间 [CI]：0.711-0.984），当第 3 天重复 ISTH 显性 DIC 筛查时，这种关联变得更强（IPTW 调整的 HR：0.727；95%CI：0.597-0.884）。此外，我们观察到使用日本急性医学协会标准进行 DIC 筛查与死亡率相关的几乎可比的效果。