Prognostic value of sepsis-induced coagulation abnormalities: an early assessment in the emergency department
- 15 Downloads
To evaluate if the assessment of coagulation abnormalities at ED admission could improve prognostic assessment of septic patients. This report utilizes a portion of the data collected in a prospective study, with the aim to identify reliable biomarkers for an early sepsis diagnosis. In the period November 2011–December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis severe sepsis/septic shock. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24): D-dimer, thrombin–antithrombin complex (TAT) and prothrombin fragment F1 + 2 levels were analyzed. The primary end-points were day-7 and in-hospital mortality. Day-7 mortality rate was 16%. D-dimer (T0: 4661 ± 4562 µg/ml vs 3190 ± 7188 µg/ml; T6: 4498 ± 4931 µg/ml vs 2822 ± 5623 µg/ml; T24 2905 ± 2823 µg/ml vs 2465 ± 4988 µg/ml, all p < 0.05) and TAT levels (T0 29 ± 45 vs 22 ± 83; T6 21 ± 22 vs 15 ± 35; T24 16 ± 19 vs 13 ± 30, all p < 0.05) were higher among non-survivors compared to survivors. We defined an abnormal coagulation activation (COAG+) as D-dimer > 500 µg/ml and TAT > 8 ng/ml (for both, twice the upper normal value). Compared to COAG−, COAG+ patients showed higher lactate levels at the earliest evaluations (T0: 3.3 ± 2.7 vs 2.5 ± 2.3, p = 0.041; T6: 2.8 ± 3.4 vs 1.8 ± 1.6, p = 0.015); SOFA score was higher after 24 h (T24: 6.7 ± 3.1 vs 5.4 ± 2.9, p = 0.008). At T0, COAG+ patients showed a higher day-7 mortality rate (HR 2.64; 95% CI 1.14–6.11, p = 0.023), after adjustment for SOFA score and lactate level. Presence of abnormal coagulation at ED admission shows an independent association with an increased short-term mortality rate.
KeywordsSepsis Coagulation abnormalities Prognostic stratification
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Statement of human and animal rights
The study was conducted in compliance with the Declaration of Helsinki at the Careggi University Hospital.
The study protocol was approved by the local Ethics Committee, and all subjects provided oral.
- 1.Kinasewitz GT, Yan SB, Basson B, Comp P, Russell JA, Cariou A, Um SL, Utterback B, Laterre PF, Dhainaut JF (2004) Universal changes in biomarkers of coagulation and inflammation occur in patients with severe sepsis, regardless of causative micro-organism [ISRCTN74215569]. Crit Care 8(2):R82–R90. https://doi.org/10.1186/cc2459 CrossRefPubMedPubMedCentralGoogle Scholar
- 2.Collins PW, Macchiavello LI, Lewis SJ, Macartney NJ, Saayman AG, Luddington R, Baglin T, Findlay GP (2006) Global tests of haemostasis in critically ill patients with severe sepsis syndrome compared to controls. Br J Haematol 135(2):220–227. https://doi.org/10.1111/j.1365-2141.2006.06281.x CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Koyama K, Madoiwa S, Nunomiya S, Koinuma T, Wada M, Sakata A, Ohmori T, Mimuro J, Sakata Y (2014) Combination of thrombin-antithrombin complex, plasminogen activator inhibitor-1, and protein C activity for early identification of severe coagulopathy in initial phase of sepsis: a prospective observational study. Crit Care 18(1):R13. https://doi.org/10.1186/cc13190 CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Angstwurm MW, Dempfle CE, Spannagl M (2006) New disseminated intravascular coagulation score: a useful tool to predict mortality in comparison with Acute Physiology and Chronic Health Evaluation II and Logistic Organ Dysfunction scores. Crit Care Med 34(2):314–320 (00003246-200602000-00005 [pii]) CrossRefPubMedGoogle Scholar
- 6.Schwameis M, Steiner MM, Schoergenhofer C, Lagler H, Buchtele N, Jilma-Stohlawetz P, Boehm T, Jilma B (2015) D-dimer and histamine in early stage bacteremia: a prospective controlled cohort study. Eur J Intern Med 26(10):782–786. https://doi.org/10.1016/j.ejim.2015.10.024 CrossRefPubMedGoogle Scholar
- 7.Adamik B, Gozdzik W, Jakubczyk D, Welna M, Kubler A (2017) Coagulation abnormalities identified by thromboelastometry in patients with severe sepsis: the relationship to endotoxemia and mortality. Blood Coagul Fibrinolysis 28(2):163–170. https://doi.org/10.1097/mbc.0000000000000572 CrossRefPubMedGoogle Scholar
- 8.Innocenti F, Bianchi S, Guerrini E, Vicidomini S, Conti A, Zanobetti M, Pini R (2014) Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit. Eur J Emerg Med 21(4):254–259. https://doi.org/10.1097/mej.0000000000000075 CrossRefPubMedGoogle Scholar
- 9.Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Crit Care Med 31(4):1250–1256. https://doi.org/10.1097/01.ccm.0000050454.01978.3b CrossRefPubMedGoogle Scholar
- 15.Couto-Alves A, Wright VJ, Perumal K, Binder A, Carrol ED, Emonts M, de Groot R, Hazelzet J, Kuijpers T, Nadel S, Zenz W, Ramnarayan P, Levin M, Coin L, Inwald DP (2013) A new scoring system derived from base excess and platelet count at presentation predicts mortality in paediatric meningococcal sepsis. Crit Care 17(2):R68. https://doi.org/10.1186/cc12609 CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Jones AE, Trzeciak S, Kline JA (2009) The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med 37(5):1649–1654. https://doi.org/10.1097/ccm.0b013e31819def97 CrossRefPubMedPubMedCentralGoogle Scholar