Disseminated intravascular coagulation with the fibrinolytic phenotype predicts the outcome of patients with out-of-hospital cardiac arrest

Abstract

BackgroundWe tested the hypothesis that disseminated intravascular coagulation (DIC) during the early phase of post-cardiopulmonary resuscitation (CPR) is associated with systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS) and affects the outcome of out-of-hospital cardiac arrest (OHCA) patients.MethodsA review of the computer-based medical records of OHCA patients was retrospectively conducted and included 388 patients who were divided into DIC and non-DIC patients based on the Japanese Association for Acute Medicine DIC diagnostic criteria. DIC patients were subdivided into two groups: those with and without hyperfibrinolysis. Pre-hospital factors, platelet count, coagulation and fibrinolysis markers and lactate levels within 24 h after resuscitation were evaluated. The outcome measure was all-cause hospital mortality.ResultsDIC patients exhibited lower platelet counts, prolonged prothrombin time, decreased levels of fibrinogen and antithrombin associated with increased fibrinolysis than those without DIC. DIC patients more frequently developed SIRS and MODS, followed by worse outcomes than non-DIC patients. The same changes were observed in DIC patients with hyperfibrinolysis who showed a higher prevalence of MODS, leading to worse outcome than those without hyperfibrinolysis. Logistic regression analyses showed that lactate levels predicted hyperfibrinolysis and DIC is an independent predictor of patient death. Survival probabilities of DIC patients during hospital stay were significantly lower than non-DIC patients. The area under the receiver operating characteristic curve of DIC for the prediction of death was 0.704.ConclusionsThe fibrinolytic phenotype of DIC during the early phase of post-CPR more frequently results in SIRS and MODS, especially in patients with hyperfibrinolysis, and affects the outcome of OHCA patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12959-016-0116-y) contains supplementary material, which is available to authorized users.

Disseminated intravascular coagulation in cardiac arrest and resuscitation

“…In addition, the TFPI levels did not match the increased levels of tissue factor from arrival at the ED to 24 hours after admission in patients with ROSC after cardiac arrest. Low levels of antithrombin were also confirmed in patients after cardiac arrest and resuscitation, especially in non‐survivors and patients with DIC . An experimental study supported these results, showing that antithrombin levels decrease with mirror‐image increases in TAT levels after CPR in a pig cardiac arrest model …”

“…It should be noted that the duration of increased fibrinolysis is very short (~3 hours after the insult) and that thrombin generation due to the activation of coagulation and impairment of the anticoagulation pathways always underlies the changes in fibrinolysis. Increased fibrinolysis due to the release of t‐PA before expression of PAI‐1 mRNA may be called DIC with the fibrinolytic phenotype, which subsequently proceeds to usual thrombotic DIC in patients after cardiac arrest and resuscitation …”

“…Increased DIC scores on admission to the ED are associated with in‐hospital and 6‐month death, and an unfavorable long‐term neurologic outcome as assessed by the use of CPC scores in patients after cardiac arrest and resuscitation . Both types of DIC, fibrinolytic and thrombotic, are reported to be associated with multiple organ dysfunction, low survival probability, and a high rate of in‐hospital mortality. In addition to DIC scores, both hyperfibrinolysis (defined as fibrin/fibrinogen degradation product [FDP] levels of >100 μg/mL) and fibrinolytic shutdown (assessed by measurement of t‐PA‐PAI‐1 complex levels) were found to be associated with in‐hospital death or increased SOFA scores .…”

Fibrin/fibrinogen degradation products (FDP) at hospital admission predict neurological outcomes in out-of-hospital cardiac arrest patients

“…19,23 Based on assessment of the mortality rate in OHCA patients one month after cardiac arrest, DIC with the fibrinolytic phenotype predicted the outcome. 26 However, neurological outcomes of OHCA patients were not assessed.…”

Differences in coagulofibrinolytic changes between post‐cardiac arrest syndrome of cardiac causes and hypoxic insults: a pilot study

“…Systemic hypoxia, ischemia, and reperfusion cause endothelial damage with a consequent increase in tissue factor activity, which forms a complex with factor VII/VIIa, and the complex results in the generation of thrombin 2. Moreover, anoxia and endothelial injury lead to hyperfibrinolysis 3. These findings indicate that the hypoxia‐induced endothelial injury of the hypoxic PCAS patients was more serious.…”