Prospective study of early onset coagulopathy as a predictor of outcome in septicaemic patients admitted to a tertiary care centre in eastern India
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Abstract
Background: Severe sepsis and septic shock are among the leading causes of morbidity and mortality in intensive care units worldwide despite rapid advances in treatment protocols. Even with all advances, determining the prognosis of sepsis continues to remain tricky.
Objectives: This study was planned to assess early onset coagulopathy as a predictor of outcome and mortality in septicemic patients and to study the underlying risk factors associated with mortality in septicemic patients with underlying coagulopathy.
Materials and methods: 240 patients fulfilling the criteria of SIRS and sepsis were included in the study. Coagulation parameters including platelet count, prothrombin time – international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT) were evaluated within 48 hours of admission and 28-day mortality was evaluated. Independent predictors of 28-day mortality were evaluated using logistic regression model.
Results:Twenty-eight-day mortality rate was 77.77% (98/126) in patients with coagulopathy and a meagre 1.7% (2/114) in patients without coagulopathy which was statistically significant (p<0.05). Log Odd’s ratio calculated using chi-square test was found to be 5.2781, 95% CI (1.633-17.321), which was highly significant. Univariate logistic regression for mortality showed PT-INR, aPTT and APACHE II
scores to be independent variables. Multivariate logistic regression revealed severe increase in PT-INR [adjusted OR=1.622 (0.841, 3.092)], moderate increase in aPTT [adjusted OR=4.537 (0.989, 7.326)], and severe increases in aPTT [adjusted OR=3.851 (2.438, 4.996)], and APACHE II scores [adjusted OR=5.381 (1.925, 11.01)], were independently associated with 28-day mortality whereas age, sex, any severity of thrombocytopenia, mild to moderate increase in PT-INR, and mild increase in aPTT were not.
Conclusion: Early onset coagulopathy was found to be significantly associated with increased mortality risk in septicemic patients. Septicemic patients should be screened for coagulopathy within 24-48 hours of admission in appropriate clinical scenario to predict mortality outcome and take necessary action at the earliest.
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References
Annane D, Bellissant E, Cavaillon J-M. Septic shock. Lancet [Internet]. 2005; 365(9453): 63-78. Available from: http://dx.doi.org/10.1016/S0140-6736(04)17667-8.
Cohen J. The immunopathogenesis of sepsis. Nature [Internet]. 2002; 420(6917): 885-91. Available from: http://dx.doi.org/10.1038/nature01326.
Hunt BJ. Bleeding and coagulopathies in critical care. N Engl J Med [Internet]. 2014; 370(22): 2153. Available from: http://dx.doi.org/10.1056/NEJMc1403768.
Schouten M, Wiersinga WJ, Levi M, van der Poll T. Inflammation, endothelium, and coagulation in sepsis. J Leukoc Biol [Internet]. 2008; 83(3): 536–45. Available from: http://dx.doi.org/10.1189/jlb.0607373.
Pawlinski R, Mackman N. Cellular sources of tissue factor in endotoxemia and sepsis. Thromb Res [Internet]. 2010;125 Suppl 1:S70-3. Available from: http://dx.doi.org/10.1016/j.thromres.2010.01.042.
Mosad E, Elsayh KI, Eltayeb AA. Tissue factor pathway inhibitor and P-selectin as markers of sepsis-induced non-overt disseminated intravascular coagulopathy. Clin Appl Thromb Hemost [Internet]. 2011; 17(1): 80-7. Available from: http://dx.doi.org/10.1177/1076029609344981.
Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, et al. Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med [Internet]. 2002; 28(2): 108-21. Available from: http://dx.doi.org/10.1007/s00134-001-1143-z.
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med [Internet]. 2003; 348(16): 1546-54. Available from: http://dx.doi.org/10.1056/NEJMoa022139.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985; 13(10): 818-29.
Levi M, Opal SM. Coagulation abnormalities in critically ill patients. In: Surgical Intensive Care Medicine. Cham: Springer International Publishing; 2016. p. 463-71.
Guitton C, Gérard N, Sébille V, Bretonnière C, Zambon O, Villers D, et al. Early rise in circulating endothelial protein C receptor correlates with poor outcome in severe sepsis. Intensive Care Med [Internet]. 2011; 37(6): 950-6. Available from: http://dx.doi.org/10.1007/s00134-011-2171-y.
Venkata C, Kashyap R, Farmer JC, Afessa B. Thrombocytopenia in adult patients with sepsis: incidence, risk factors, and its association with clinical outcome. J Intensive Care [Internet]. 2013; 1(1): 9. Available from: http://dx.doi.org/10.1186/2052-0492-1-9.
Chakraverty R, Davidson S, Peggs K, Stross P, Garrard C, Littlewood TJ. The incidence and cause of coagulopathies in an intensive care population. Br J Haematol [Internet]. 1996; 93(2): 460-3. Available from: http://dx.doi.org/10.1046/j.1365-2141.1996.5101050.x.
Sharma B, Sharma M, Majumder M, Steier W, Sangal A, Kalawar M. Thrombocytopenia in septic shock patients--a prospective observational study of incidence, risk factors and correlation with clinical outcome. Anaesth Intensive Care [Internet]. 2007; 35(6): 874-80. Available from: http://dx.doi.org/10.1177/0310057X0703500604.
Todi S, Chatterjee S, Sahu S, Bhattacharyya M. Epidemiology of severe sepsis in India: an update. Crit Care [Internet]. 2010; 14(Suppl 1): P382. Available from: http://dx.doi.org/10.1186/cc8614.
Pfister R, Kochanek M, Leygeber T, Brun-Buisson C, Cuquemelle E, Machado MB, et al. Procalcitonin for diagnosis of bacterial pneumonia in critically ill patients during 2009 H1N1 influenza pandemic: a prospective cohort study, systematic review and individual patient data meta-analysis. Crit Care
[Internet]. 2014; 18(2): R44. Available from: http://dx.doi.org/10.1186/cc13760.
Li B, Zhao X, Li S. Serum procalcitonin level and mortality risk in critically ill patients with ventilator-associated pneumonia. Cell Physiol Biochem [Internet]. 2015; 37(5): 1967-72. Available from: http://dx.doi.org/10.1159/000438557.
Naved SA, Siddiqui S, Khan FH. APACHE-II score correlation with mortality and length of stay in an intensive care unit. J Coll Physicians Surg Pak [Internet]. 2011; 21(1): 4-8. Available from: http://dx.doi.org/01.2011/JCPSP.0408.
Desai S, Lakhani JD. Utility of SOFA and APACHE II score in sepsis in rural set up MICU. J Assoc Physicians India. 2013; 61(9): 608-11.
Dhainaut J-F, Shorr AF, Macias WL, Kollef MJ, Levi M, Reinhart K, et al. Dynamic evolution of coagulopathy in the first day of severe sepsis: relationship with mortality and organ failure. Crit Care Med [Internet]. 2005; 33(2): 341-8. Available from: http://dx.doi.org/10.1097/01.ccm.0000153520.31562.48.
Martin GS, Mannino DM, Moss M. The effect of age on the development and outcome of adult sepsis. Crit Care Med [Internet]. 2006; 34(1): 15-21. Available from: http://dx.doi.org/10.1097/01.ccm.0000194535.82812.ba.
Nasa P, Juneja D, Singh O, Dang R, Arora V. Severe sepsis and its impact on outcome in elderly and very elderly patients admitted in intensive care unit. J Intensive Care Med [Internet]. 2012; 27(3): 179-83. Available from: http://dx.doi.org/10.1177/0885066610397116.
Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med [Internet]. 2001; 29(7): 1303-10. Available from: http://dx.doi.org/10.1097/00003246-200107000-00002.
Adrie C, Azoulay E, Francais A, Clec’h C, Darques L, Schwebel C, et al. Influence of gender on the outcome of severe sepsis: a reappraisal. Chest [Internet]. 2007; 132(6): 1786-93. Available from: http://dx.doi.org/10.1378/chest.07-0420.
Wang HE, Shapiro NI, Griffin R, Safford MM, Judd S, Howard G. Chronic medical conditions and risk of sepsis. PLoS One [Internet]. 2012; 7(10): e48307. Available from: http://dx.doi.org/10.1371/journal.pone.0048307.