Evaluation of Criteria of DIC in Pediatric Patients
Evaluation of Criteria of DIC in Pediatric Patients
Globally, adult intensive care units routinely use the International Society on Thrombosis and Haemostasis (ISTH) scoring system for identifying overt disseminated intravascular coagulation (DIC). However, in our pediatric intensive care unit, a modified diagnostic criterion (Texas Children's Hospital [TCH] criteria) that requires serial monitoring of the coagulation variables is employed. A retrospective analysis of 2,136 DIC panels from 130 patients who had at least 4 DIC panels during 1 admission to a pediatric intensive care unit was done to compare the diagnostic utility of the TCH criteria with the ISTH scoring method in children. Both scoring systems were evaluated against the gold standard diagnostic method of autopsy confirmation of DIC in the subset of children who died. Receiver operating characteristic analysis indicates that TCH diagnostic criteria are comparable to the ISTH scoring method (area under the curve of 0.878 for TCH and 0.950 for ISTH). On the contrary, TCH diagnostic criteria perform better, with a sensitivity significantly higher than the ISTH scoring method when tested against the gold standard (P < .05). Fibrinogen is not a significant predictor of overt DIC in both models. Sequential testing of coagulation parameters is recommended for improved sensitivity when applying ISTH criteria to pediatric populations.
Overt disseminated intravascular coagulation (DIC) in children is a spectrum of manifestations of severe systemic activation of coagulation. Diagnosis of DIC is complicated because it includes a wide range of clinical presentation, including mild to excessive bleeding and systemic thromboembolic phenomenon, and is associated with multiorgan failure. The lack of a gold standard for laboratory diagnosis of overt DIC has added to the difficulty in identifying and clinically managing this disorder.
The International Society on Thrombosis and Haemostasis (ISTH) diagnostic scoring system for overt DIC has been widely used in intensive care units, and many outcome studies validating the ISTH diagnostic score against morbidity scores have been published (eg, logistic organ dysfunction, Acute Physiology and Chronic Health Evaluation, and Pediatric Risk of Mortality III). Although the common predisposing conditions for DIC are not the same in adults and children, the pathophysiology remains the same, with an overwhelmed hemostatic system that is unable to cope with continuous thrombin activation and the consumption of coagulation factors and platelets.
In pediatrics, however, there are still controversies regarding the varying manifestations of DIC in subsets of critically ill children, wide ranges of coagulation parameters in different age groups, and the choice of confirmatory laboratory tests for overt DIC. In our pediatric intensive care unit (PICU), the standard method of diagnosis is expert opinion based on criteria that include sequential testing of the components of the ISTH scoring system (ie, prothrombin time [PT], platelet count, fibrinogen, and D-dimer). Despite the fact that many PICUs in the United States routinely use the ISTH scoring system, there is a paucity of clinical research studies examining its utility in children.
In this article, we examine the predictive ability of the global coagulation tests to identify patients with overt DIC and also compare our Texas Children's Hospital (TCH) criteria with the ISTH diagnostic algorithm. Furthermore, a small subset of patients (n = 24) provided a gold standard (ie, autopsy results) against which we compared the performance of the ISTH score and our hospital's modified criteria.
Abstract and Introduction
Abstract
Globally, adult intensive care units routinely use the International Society on Thrombosis and Haemostasis (ISTH) scoring system for identifying overt disseminated intravascular coagulation (DIC). However, in our pediatric intensive care unit, a modified diagnostic criterion (Texas Children's Hospital [TCH] criteria) that requires serial monitoring of the coagulation variables is employed. A retrospective analysis of 2,136 DIC panels from 130 patients who had at least 4 DIC panels during 1 admission to a pediatric intensive care unit was done to compare the diagnostic utility of the TCH criteria with the ISTH scoring method in children. Both scoring systems were evaluated against the gold standard diagnostic method of autopsy confirmation of DIC in the subset of children who died. Receiver operating characteristic analysis indicates that TCH diagnostic criteria are comparable to the ISTH scoring method (area under the curve of 0.878 for TCH and 0.950 for ISTH). On the contrary, TCH diagnostic criteria perform better, with a sensitivity significantly higher than the ISTH scoring method when tested against the gold standard (P < .05). Fibrinogen is not a significant predictor of overt DIC in both models. Sequential testing of coagulation parameters is recommended for improved sensitivity when applying ISTH criteria to pediatric populations.
Introduction
Overt disseminated intravascular coagulation (DIC) in children is a spectrum of manifestations of severe systemic activation of coagulation. Diagnosis of DIC is complicated because it includes a wide range of clinical presentation, including mild to excessive bleeding and systemic thromboembolic phenomenon, and is associated with multiorgan failure. The lack of a gold standard for laboratory diagnosis of overt DIC has added to the difficulty in identifying and clinically managing this disorder.
The International Society on Thrombosis and Haemostasis (ISTH) diagnostic scoring system for overt DIC has been widely used in intensive care units, and many outcome studies validating the ISTH diagnostic score against morbidity scores have been published (eg, logistic organ dysfunction, Acute Physiology and Chronic Health Evaluation, and Pediatric Risk of Mortality III). Although the common predisposing conditions for DIC are not the same in adults and children, the pathophysiology remains the same, with an overwhelmed hemostatic system that is unable to cope with continuous thrombin activation and the consumption of coagulation factors and platelets.
In pediatrics, however, there are still controversies regarding the varying manifestations of DIC in subsets of critically ill children, wide ranges of coagulation parameters in different age groups, and the choice of confirmatory laboratory tests for overt DIC. In our pediatric intensive care unit (PICU), the standard method of diagnosis is expert opinion based on criteria that include sequential testing of the components of the ISTH scoring system (ie, prothrombin time [PT], platelet count, fibrinogen, and D-dimer). Despite the fact that many PICUs in the United States routinely use the ISTH scoring system, there is a paucity of clinical research studies examining its utility in children.
In this article, we examine the predictive ability of the global coagulation tests to identify patients with overt DIC and also compare our Texas Children's Hospital (TCH) criteria with the ISTH diagnostic algorithm. Furthermore, a small subset of patients (n = 24) provided a gold standard (ie, autopsy results) against which we compared the performance of the ISTH score and our hospital's modified criteria.
