Incidence of disseminated intravascular coagulation in critically ill cancer patients

Disseminated intravascular coagulation (DIC) is an acquired clinical syndrome characterized by the intravascular activation of coagulation with a loss of regulation and arising from different causes, thereby compromising the adequate supply of blood to various organs by widespread (micro) vascular thrombosis, and reducing oxygen delivery to cells and tissues, which may contribute to the development of multiple organ failure.^1,2 Cancer patients at admission to the intensive care unit (ICU) frequently have acute conditions associated with DIC, such as sepsis or medical or surgical problems that arise from or are exacerbated during antineoplastic treatment or after postoperative care following complex procedures. ³ We present the results of an observational prospective cohort study at the ICU of Instituto Nacional de Cancerologia located in Mexico City. The aim was to describe the incidence of DIC and its related risk factors in a group of critically ill cancer patients upon admission to the ICU. We included all consecutive patients admitted to the ICU during the period between December 2015 and May 2016. This study was approved by the Institutional Review Board (INCAN/CI/480/17). A DIC diagnosis was made based on the International Society on Thrombosis and Hemostasis (ISTH) diagnosis criteria. A score ≥5 points is compatible with overt DIC. ⁴

A total of 120 patients were included. A diagnosis of DIC was made in 15 of 120 patients (12.5%). Patients had a mean age of 50.7 ± 15.5 years, and 58.3% (70 patients) were men. Solid tumors were the predominant type of malignancy; however, this was not significantly different from hematological neoplasms. The most relevant differences between patients with and without DIC were ICU admission with septic shock (66.7% vs. 15.2%, p < 0.001), presence of bacteremia (33.3% vs. 6.67%, p = 0.001), APACHE II score points (18.07 ± 5.03 vs. 11.88 ± 7.07, p < 0.001), Sequential Organ Failure Assessment (SOFA) score points (9.87 ± 3.64 vs. 5.84 ± 3.11, p = 0.001) and Mexican SOFA (MEXSOFA) score points (11.6 ± 2.72 vs. 7.88 ± 3.95, p < 0.001). The patients with DIC had a higher proportion of hemodynamic and hematological failure (organ dysfunction was defined by a SOFA score ≥ 2 points). ⁵ Finally, we evaluated the potential risk factors for developing DIC upon admission to the ICU. The results indicate that admission to the ICU with septic shock (RR 5.08, 95% CI: 1.34–19.27, p = 0.020) and a higher SOFA score (RR 1.32, 95% CI: 1.06–1.62, p = 0.010) are associated with the presence of DIC upon admission to ICU. The ICU mortality rates for patients who had DIC and for those without DIC were 26.7% and 11.4%, respectively (p = 0.120). The incidence of DIC in critically ill cancer patients has not been previously reported. In this study, we found a low incidence of DIC at the time of admission to the ICU. Critically ill cancer patients admitted to the ICU with septic shock or higher SOFA scores have an increased risk of presenting with DIC upon admission to the ICU. The identification of risk factors and the early diagnosis of DIC will allow early interventions and improve the outcome of critically ill cancer patients in the ICU.