Helms Julie, Severac François, Merdji Hamid, Clere-Jehl Raphaël, François Bruno, Mercier Emmanuelle, Quenot Jean-Pierre, Meziani Ferhat
Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive Réanimation, Nouvel Hôpital Civil, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.
ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg (UNISTRA), Strasbourg, France.
Ann Intensive Care. 2020 Jul 10;10(1):92. doi: 10.1186/s13613-020-00704-5.
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.
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.
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.
目前尚无诊断脓毒性休克诱发的弥散性血管内凝血（DIC）的金标准。我们这项多中心前瞻性研究的目的是评估不同主要评分系统在预测死亡率和诊断DIC方面的表现。对JAAM - DIC 2016评分、ISTH显性DIC 2001评分、脓毒症诱发凝血病（SIC）评分与JAAM - DIC 2016或ISTH显性DIC评分的联合应用，在因脓毒性休克入住重症监护病房（第1天）12小时内及第2天的患者中进行了测试。
582例患者纳入研究。根据ISTH显性DIC评分，182/567例（32.1%）被诊断为DIC；根据JAAM - DIC评分，193/561例（34.4%）被诊断为DIC；486/577例患者（84.2%）根据SIC评分被诊断为凝血病。ISTH显性DIC与JAAM - DIC之间观察到中度一致性[κ = 0.67（0.60，0.73），p < 0.001]。早期DIC患者中，JAAM - DIC评分与ISTH显性DIC评分的阳性延迟时间无差异。尽管SIC评分更早呈阳性，但其诊断特异性较差，因为84.2%的脓毒性休克患者被诊断为“凝血病”。单独SIC评分预测死亡率的特异性非常低[0.18（0.15；0.22）]，与JAAM - DIC评分[0.71（0.67；0.75）]和ISTH显性DIC评分[0.76（0.72；0.80）]相比，p < 0.001。SIC评分预测死亡率的敏感性为0.95[0.89；0.98]，JAAM - DIC评分和ISTH显性DIC评分的敏感性分别为0.61[0.50；0.70]和0.68[0.58；0.77]。与单独的JAAM - DIC评分或ISTH显性DIC评分相比，将SIC评分与JAAM - DIC评分或ISTH显性DIC评分联合应用在敏感性和特异性方面并无益处。
我们的数据表明，单独的SIC评分或与其他评分联合应用的附加值有限，JAAM - DIC评分和ISTH显性DIC评分均可用于脓毒性休克患者。试验注册 临床试验；试验注册号：NCT02391792；注册日期：2015年3月18日；试验注册记录网址：https://clinicaltrials.gov/ct2/show/NCT02391792?term=meziani&draw=4&rank=1 。
