From the Guidelines
When a patient with sepsis has elevated PTT, PT, INR, and D-dimer, it is crucial to promptly manage the underlying sepsis and consider a hematology consultation, as this suggests disseminated intravascular coagulation (DIC), which requires supportive care with blood products as needed. The patient's condition should be closely monitored with a comprehensive coagulation workup, including fibrinogen, fibrin degradation products, platelet count, peripheral blood smear, and repeat coagulation studies every 6-12 hours to monitor progression 1. Key management strategies include:
- Treating the underlying sepsis with appropriate antibiotics and source control
- Providing supportive care with blood products as needed, such as:
- Platelets for counts below 50,000/μL with active bleeding or below 20,000/μL without bleeding
- Cryoprecipitate for fibrinogen below 100 mg/dL
- Fresh frozen plasma for active bleeding with prolonged coagulation times
- Avoiding prophylactic anticoagulation until DIC resolves, as suggested by recent guidelines 1. The abnormalities in coagulation parameters occur because sepsis triggers systemic inflammation and dysregulated coagulation, leading to simultaneous clot formation and consumption of clotting factors, resulting in both thrombosis and bleeding risk 1. Recent studies, such as the one published in 2023, emphasize the importance of sepsis-induced coagulopathy in the management of sepsis and suggest that anticoagulant therapy may be beneficial in patients with sepsis-induced coagulopathy 1. However, the management approach should be individualized based on the patient's specific condition and risk factors, and a hematology consultation is recommended to guide the management of DIC and coagulopathy in sepsis 1.
From the Research
Elevated PT, INR, and D-Dimer in Sepsis
- In patients with sepsis, elevated prothrombin time (PT), international normalized ratio (INR), and D-dimer are associated with increased mortality and morbidity 2, 3, 4, 5
- A study found that PT > 16.5 s was an independent risk factor for septic shock and 28-day mortality 2
- Another study showed that D-dimer corrected for thrombin and plasmin generation is a strong predictor of mortality in patients with sepsis 3
Diagnostic and Prognostic Significance of PT/INR
- The PT/INR has moderate diagnostic accuracy for septic shock and is associated with reliable prognostic accuracy for 30-day all-cause mortality in patients with sepsis and septic shock 5
- A PT/INR > 1.5 is associated with higher rates of 30-day all-cause mortality in patients with sepsis and septic shock 5
Laboratory Tests and Workup
- Routine coagulation tests, including PT, INR, activated partial thromboplastin time (APTT), and D-dimer, should be ordered in patients with sepsis and septic shock 2, 3, 4, 5
- Other laboratory tests, such as platelet count, fibrinogen, and antithrombin, may also be useful in evaluating the coagulation status of patients with sepsis and septic shock 2, 4
Hematology/Oncology Consultation
- A hematology/oncology consultation may be considered in patients with sepsis and septic shock who have significant coagulopathy or thrombocytopenia, or who require management of bleeding or thrombotic complications 6