Incidence of Sepsis-Related Coagulopathy
The incidence of sepsis-related coagulopathy (SIC) is approximately 60-61% in patients with severe sepsis or septic shock, which is significantly higher than the 29-30% incidence of overt disseminated intravascular coagulation (DIC) in this population. 1
Diagnostic Criteria and Incidence Rates
Sepsis-induced coagulopathy represents a spectrum of coagulation abnormalities that can range from mild platelet and coagulation factor dysfunction to full-blown DIC. Several diagnostic scoring systems are used to identify and classify the severity of coagulopathy in sepsis:
Sepsis-Induced Coagulopathy (SIC) Score:
- Incidence: 60.8% of patients with sepsis 1
- Components: Platelet count, PT ratio, and SOFA score
- Threshold: ≥4 points indicates SIC
Japanese Association for Acute Medicine (JAAM) DIC Score:
- Incidence: 61.4% of patients with sepsis 1
- Similar incidence to SIC but different diagnostic criteria
International Society on Thrombosis and Haemostasis (ISTH) Overt DIC Score:
- Incidence: 29.3% of patients with sepsis 1
- Represents more severe, decompensated coagulopathy
Mortality Rates Associated with Coagulopathy
The presence of coagulopathy significantly impacts mortality in sepsis:
- SIC: 28-day mortality of 32.5-37.2% 1
- JAAM DIC: 28-day mortality of 33.9-49.1% 1
- ISTH Overt DIC: 28-day mortality of 38.4-58.7% 1
These figures demonstrate that the development of coagulopathy in sepsis is associated with substantially increased mortality risk, with more severe forms of coagulopathy correlating with higher mortality rates.
Pathophysiology and Risk Factors
Sepsis-related coagulopathy develops through several mechanisms:
- Inflammatory cytokine release triggering tissue factor expression
- Endothelial dysfunction impairing anticoagulant pathways
- Suppression of fibrinolysis due to plasminogen activator inhibitor-1 overproduction
- Release of neutrophil extracellular traps (NETs) with prothrombotic properties 2
Risk factors for developing coagulopathy in sepsis include:
- Mechanical ventilation >48 hours (OR = 15.6, p < 0.001) 1
- Pre-existing coagulopathy (OR = 4.3, p < 0.001) 1
- Multi-organ dysfunction
- Severe inflammatory response
Clinical Implications and Management
The presence of coagulopathy in sepsis has important clinical implications:
- Patients with respiratory failure and coagulopathy have a 3.7% risk of clinically important gastrointestinal bleeding (95% CI 2.5-5.2%) 1
- SIC is an independent risk factor for 7-day and 28-day mortality with an adjusted odds ratio of 1.52 (95% CI: 1.39-1.67) 1
- Early identification of SIC may help identify candidates for specific interventions
Management approaches should focus on:
- Treating the underlying sepsis (source control and appropriate antimicrobials)
- Supportive care for organ dysfunction
- Consideration of specific anticoagulant therapies in selected patients:
Monitoring and Prognostication
Regular monitoring of coagulation parameters is essential in septic patients:
- Platelet count
- Prothrombin time (PT)
- D-dimer levels
- SOFA score components
The SIC score has demonstrated good negative predictive value (95.7%) for overt DIC, making it a useful screening tool 1. Progressive worsening of coagulation parameters correlates with increased mortality risk and should prompt intensification of monitoring and care.
Pitfalls and Caveats
- Different diagnostic criteria for coagulopathy make comparison between studies challenging
- The presence of SIC does not automatically indicate the need for anticoagulant therapy - treatment decisions should be based on the overall clinical picture
- Coagulopathy in sepsis can manifest as both bleeding and thrombotic complications
- Mortality prediction should primarily rely on comprehensive organ dysfunction scoring systems like SOFA and APACHE II rather than coagulation scores alone 1