Prognosis of overt disseminated intravascular coagulation in patients admitted to a medical emergency department

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Abstract

Objective

To assess the prevalence, characteristics and prognosis of overt disseminated intravascular coagulation (DIC) in adult emergency department (ED) patients and identify markers of poor outcome.

Materials and methods

In a chart review study, we analysed the occurrence of overt DIC in all patients (n=1 001 727) attending the University’s ED from 2003 to 2014 applying the ISTH DIC score. The primary outcome measure was 30-day mortality. Logistic regression analysis was used to determine predictors of mortality.

Results

The initial inter-rater reliability in the diagnosis of DIC was 0.85 [κ; 95% confidence interval (CI), 0.77–0.92]. The main DIC precipitators were malignancy (47%), cardiovascular diseases (CVD, 27%) and sepsis (16%). Hyperfibrinolytic DIC occurred in 27% of patients and was over-represented in those with cardiac arrest (68%). Thirty-day mortality (52%) was inversely associated with fibrinogen levels on admission [adjusted odds ratio, 0.49; 95% CI: 0.30–0.82; P=0.006]. Afibrinogenaemia implied an even 10-fold increased risk of dying (crude odds ratio, 10.0; 95% CI: 3.2–31.4; P<0.001). D-dimer and platelet count had no predictive value. Appropriate ICD-10 coding for DIC was present in only 1.8% of cases.

Conclusion

Overt DIC is a rare but underdiagnosed event in ED patients. In this collective, cardiac arrest is a dominant cause of DIC presenting with a fibrinolytic phenotype. The degree of hypofibrinogenaemia on admission strongly and linearly predicted early death.

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