Should coagulation be corrected in a septic shock patient?

Coagulation Correction in Septic Shock

Do not routinely correct laboratory coagulation abnormalities in septic shock patients unless they are actively bleeding or require an invasive procedure. 1

Fresh Frozen Plasma (FFP)

Fresh frozen plasma should not be used to correct laboratory clotting abnormalities (elevated PT/INR or aPTT) in the absence of active bleeding or planned invasive procedures. 1 This is a consistent recommendation across the Surviving Sepsis Campaign guidelines, despite being based on lower quality evidence (grade 2D in 2012, weak recommendation with very low quality evidence in 2016). 1

Rationale for Withholding FFP:

• FFP transfusion typically fails to correct prothrombin time in nonbleeding patients with mild coagulation abnormalities 1
• No studies demonstrate that correction of even severe coagulation abnormalities benefits patients who are not bleeding 1
• Professional organizations only recommend FFP for documented coagulation factor deficiency with active bleeding or before surgical/invasive procedures 1

When FFP May Be Appropriate:

• Active hemorrhage with documented coagulation factor deficiency 1
• Immediately before planned invasive procedures or surgery 1

Antithrombin

Do not administer antithrombin for treatment of septic shock. 1 This is a strong recommendation (grade 1B) based on a phase III clinical trial showing no mortality benefit and increased bleeding risk when combined with heparin. 1

Platelet Transfusion Thresholds

Transfuse platelets prophylactically based on the following thresholds: 1, 2

• <10,000/mm³: Transfuse in the absence of apparent bleeding 1, 2
• <20,000/mm³: Transfuse if significant bleeding risk exists 1, 2
• ≥50,000/mm³: Target for active bleeding, surgery, or invasive procedures 1, 2

These thresholds are derived from consensus opinion and experience with chemotherapy-induced thrombocytopenia, recognizing that septic patients have both impaired platelet production and increased consumption. 1

Understanding the Coagulopathy of Sepsis

The Paradox:

Septic shock creates a complex coagulation picture that appears contradictory on standard laboratory tests: 3, 4, 5

• Hypercoagulable features: Elevated fibrinogen, increased D-dimer, reduced antithrombin, full activation of coagulation cascade 3, 4, 5
• Hypocoagulable features: Prolonged PT/aPTT, reduced thrombin generation, consumption of coagulation factors 3, 4
• Impaired fibrinolysis: Markedly elevated PAI-1 leading to inadequate clot breakdown and microvascular thrombosis 4

Why Standard Tests Mislead:

• Conventional coagulation tests (PT/INR, aPTT) primarily reflect hypocoagulation and do not capture the global hemostatic balance 3
• Thromboelastometry (ROTEM) studies demonstrate that despite abnormal PT/aPTT, most septic patients maintain overall normo-coagulable or even hypercoagulable states 3, 6
• In early sepsis and severe sepsis, clot firmness is actually increased, indicating enhanced clot structural development 6
• Only in advanced septic shock does true coagulation factor depletion occur with exhaustion of hemostasis 5

Clinical Algorithm

Step 1: Assess for Active Bleeding

• If NO active bleeding and NO planned procedure: Do not transfuse FFP regardless of PT/INR or aPTT values 1
• If active bleeding: Transfuse FFP for documented coagulation factor deficiency 1

Step 2: Evaluate Platelet Count

• Apply the thresholds above based on bleeding risk 1, 2

Step 3: Avoid Antithrombin

• Do not use antithrombin therapy regardless of antithrombin levels 1

Step 4: Focus on Source Control and Sepsis Management

• The primary intervention is treating the underlying sepsis according to Surviving Sepsis Campaign guidelines 1, 7
• Coagulation abnormalities typically resolve with successful sepsis treatment 7

Critical Pitfalls to Avoid

Do not reflexively transfuse FFP based solely on elevated PT/INR or aPTT values. 1 This is the most common error, as clinicians may interpret prolonged coagulation times as requiring correction when the patient is actually in a procoagulant state with microvascular thrombosis. 3, 4, 6

Recognize that 78% of FFP transfusions in septic patients occur without active bleeding, 3 representing inappropriate use that provides no benefit and exposes patients to transfusion risks.

Understand that the coagulopathy of sepsis is fundamentally different from other coagulopathies (e.g., liver disease, warfarin effect) where FFP correction may be appropriate. 4, 5

Do not use thrombolytic agents for septic thrombosis, as these are not recommended and may worsen outcomes. 8