What is the diagnosis for a patient with septic shock, thrombocytopenia, and coagulopathy?

From the Guidelines

The diagnosis for a patient with septic shock, thrombocytopenia, and coagulopathy is Sepsis-induced Coagulopathy (SIC) or Disseminated Intravascular Coagulation (DIC).

Diagnostic Criteria

The diagnosis of SIC is based on the following criteria:

• Platelet count
• Prothrombin time (PT)
• Sequential organ failure assessment (SOFA) score 1 The SIC scoring system is used to detect the compensated phase of DIC in sepsis, which can lead to overt DIC with disease progression.

Diagnosis Algorithm

The diagnosis algorithm for sepsis-associated DIC is a two-step process:

1. Screen for SIC using the SIC diagnostic criteria
2. If SIC is diagnosed, screen for overt DIC using the ISTH diagnostic criteria for overt DIC 1

Importance of Early Diagnosis

Early diagnosis of SIC is crucial for targeting anticoagulant therapy, which may improve outcomes in septic patients with coagulopathy or DIC 1

Anticoagulant Therapy

Anticoagulant therapy, such as unfractionated heparin (UFH), antithrombin, and thrombomodulin, may be considered for patients with SIC, but the effectiveness of these therapies is still controversial and requires further study 1

From the Research

Diagnosis of Septic Shock, Thrombocytopenia, and Coagulopathy

The diagnosis of septic shock, thrombocytopenia, and coagulopathy is complex and involves several factors.

• Thrombocytopenia is a common complication in patients with sepsis, with a reported incidence of 47.6% in adult patients admitted to the intensive care unit (ICU) with sepsis 2.
• Coagulopathy is a leading factor associated with mortality in patients with sepsis, and can range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC) 3.
• The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood, but likely involve decreased platelet production, platelet sequestration, and increased consumption 3.
• DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets 3, 4.

Clinical Manifestations and Risk Factors

The clinical manifestations of septic shock, thrombocytopenia, and coagulopathy include:

• Higher serum creatinine, SOFA score, vasopressor requirement, lower PaO2/FiO2 ratio, and higher mortality in patients with thrombocytopenia 5.
• Increased incidence of acute kidney injury, prolonged vasopressor support, and longer ICU stay in patients with thrombocytopenia 2.
• Higher risk of mortality in patients with non-resolution of thrombocytopenia 2.
• Independent risk factors for development of thrombocytopenia in septic shock include higher SOFA score, low P(a)O2/FiO2 ratio, and high vasopressor dose 5.

Differential Diagnosis

It is essential to differentiate between DIC and thrombotic microangiopathy (TMA), as TMA has become widely recognized in recent years due to the development of specific treatments 4.

• DIC and TMA can be differentiated using several algorithms, but it may be challenging to apply these algorithms to patients with coexisting DIC and TMA 4.
• A practical approach to thrombocytopenia in patients with sepsis involves initiating the diagnosis of TMA in parallel with the diagnosis of DIC, and considering the longitudinal diagnosis and treatment flow with TMA in mind 4.