Clinical Study Of The ISTH DIC-2018 Score For Prognostic Assessment Before Initiation Of Extracorporeal Membrane Oxygenation In Adult

BackgroundThe prevalence of coagulation-related complications in extracorporeal membrane pulmonary oxygenation(ECMO)is high and even leads to a poor prognosis for patients undergoing ECMO.Current coagulation assessment studies of ECMO patients have focused on their coagulation status during running time,at which time the coagulation status is complicated by a variety of factors,including the patient,anticoagulation,and the ECMO device,making it difficult to draw accurate conclusions.The ISTH DIC-2018 score,which consists of the clinically readily available laboratory parameters platelet(PLT)as well as prothrombin time(PT),fibrinogen(FIB),and D-dimer(D-D),has been widely used to assess coagulation status and prognosis in critically ill patients.However,there have been no clinical studies identified to date on the prognostic assessment of the ISTH DIC-2018 score prior to ECMO initiation in adult ECMO patients.Objective1.To retrospectively analyze whether there is a correlation between PLT as well as PT,FIB,and D-D before ECMO initiation with 28-day mortality in adult ECMO patients.2.To assess whether the ISTH DIC-2018 score prior to ECMO initiation serves as a predictor of 28-day mortality.MethodA total of 209 adult patients who received ECMO from the First Affiliated Hospital of Anhui Medical University between September 2018 and December 2022 had their clinical data collected,excluding patients with ECMO support ≤72 hours,antiplatelet drugs and/or anticoagulant therapy within 1-month,hematologic malignancies,excessive missing clinical data,age <18 years,and perinatal period.Part 1 The beginning of observation was taken as the day of ECMO initiation of patients,and clinical and laboratory parameters were taken as the worst outcomes within 24 hours before ECMO initiation,the primary observation endpoint was 28-day all-cause mortality,and secondary observation endpoints were in-hospital mortality,ICU in-hospital mortality,and the rate of successful ECMO withdrawal,and univariate analysis was used to compare the differences in the median or the component ratios between the two samples,and the data were downscaled using principal component analysis,the lasso algorithm for machine learning was used to establish a coagulation score index,and the propensity score weighting method was used to adjust the effect of confounding factors on outcomes,aiming to analyze the correlation between the abnormal variations of PLT,PT,FIB,D-D and FDP before ECMO initiation and the patients’ prognosis.Part 2 The clinical data of the above mentioned adult ECMO patients included in the study were analyzed to assess the diagnostic value of the ISTH DIC-2018 score prior to ECMO initiation,and whether the overt ISTH DIC-2018 score can predict 28-day mortality.Univariate and multivariate logistic regression analyses were used to assess the relationship between ISTH DIC-2018 score before ECMO initiation and 28-day mortality.Recipient operating characteristic(ROC)curves were plotted to determine the optimal cutoff value for the ISTH DIC-2018 score and to assess the ability of the ISTH DIC-2018 score to predict 28-day mortality.Kaplan-Meier analysis was used to compare differences in 28-day mortality between subgroups with different ISTH DIC-2018 scores.Results133 adult patients(age ≥18 years)who received ECMO for >72 hours met the inclusion criteria.Among them,72(54.14%)were V-V ECMO patients and 61(45.86%)were V-A ECMO patients.The overall mortality rate of 28-day ECMO patients was41.35%,with 43.06% in the V-V ECMO group and 39.34% in the V-A ECMO group.Part 11.ECMO patients enrolled: After adjusting for age,sex,BMI,cardiac arrest,type of ECMO,SOFA-PLT score pre-ECMO initiation,SAVE score(V-A ECMO),RESP score(V-V ECMO),laboratory indices,duration of mechanical ventilation prior to ECMO initiation,and maximal dose of norepinephrine before ECMO initiation,the patients in the high D-D group and the high FDP group showed a higher 28-day mortality rate and a lower rate of successful withdrawal,using the overlap weighting method.2.V-A ECMO group: PLT as well as PT,FIB,D-D,and FDP were analyzed by the above methods,and the results were not statistically significant.3.V-V ECMO group: After using the overlap weighting method,the low PLT group had a higher in-hospital mortality rate,the low FIB group had a higher in-hospital mortality rate,and the high D-D and high FDP groups had a higher 28-day mortality rate and a lower rate of successful withdrawal.To validate model stability,patients surviving ≤72 hours after initiation of ECMO were included,and the results indicated that the low PLT group had a higher 28-day mortality rate and a higher in-hospital mortality rate,the high D-D group had a lower rate of successful withdrawal,and the high FDP group had a higher 28-day mortality rate and a lower rate of successful withdrawal from ECMO.4.The correlation of PLT and coagulation parameters with prognosis was analyzed using Lasso regression,and the results demonstrated that abnormalities in PLT,PT,FIB,and D-D were significantly correlated with the prognosis of the patients(death at 28 days,in-hospital death,death in the ICU,and successful withdrawal)in the overall ECMO patients and in the V-V ECMO group.Part 21.ECMO patients enrolled: Five variables including age,norepinephrine dose before ECMO initiation,blood lactate,SOFA-PLT score,and ISTH DIC-2018 score were used to perform multivariate logistic regression analysis,and the ISTH DIC-2018 score was a statistically significant predictor(OR=1.376,95% confidence interval(CI): 1.095-1.730,P= 0.006).The optimal ISTH DIC-2018 score cutoff value was 4,with a sensitivity of 54.5% and specificity of 71.8% for predicting death,the area under the curve(AUC)of the DIC score was 0.678(95%CI: 0.585-0.771,P< 0.001).In the Kaplan-Meier analysis,patients with a DIC score ≥4 had a higher cumulative 28-d mortality rate compared with patients with a DIC score <4(HR=1.980,95%CI: 1.154-3.396,P=0.013).2.V-A ECMO group: Using univariate analysis,the median ISTH DIC-2018 score was higher in the non-survival subgroup than in the survival group(5VS4,P=0.024).Multivariate logistic regression analysis showed no statistically significant DIC score(P= 0.140).3.V-V ECMO group: Multivariate logistic regression analysis demonstrated that the ISTH DIC-2018 score was an independent predictor of 28 d mortality(OR=1.640;95%CI: 1.044-2.576,P= 0.032).The optimal cut-off value for the ISTH DIC-2018 score was also 4,with a sensitivity of 51.6% and a specificity of 80.0%,the AUC for the DIC score was 0.702(95%CI: 0.580-0.824,P=0.004).The 28-d cumulative mortality rate was higher in patients with a DIC score ≥4 than in those with a score <4(HR=2.285,95%CI: 1.117-4.674,P= 0.024).Conclusion1.Abnormalities in PLT,PT,FIB,D-D,and FDP before ECMO initiation were significantly associated with 28-d mortality in overall ECMO patients and in the V-V ECMO group.2.The ISTH DIC-2018 score before ECMO initiation is one of the predictors of 28-day mortality in adult ECMO patients,especially in the V-V ECMO patients.