Disseminated Intravascular Coagulation Predicts Adverse Outcomes in Children with Suspected Sepsis in the Emergency Department

Background: In disseminated intravascular coagulation (DIC), hemostatic dysregulation causes microvascular clotting and consumptive coagulopathy, resulting in hemorrhage and organ failure. It has been difficult to dissect the effects of DIC from the underlying predisposing condition, but DIC has been reported as an independent predictor of poor outcomes in adult sepsis (Voves, et al, Blood Coagulation and Fibrinolysis 2006). Epidemiologic studies demonstrate an increasing prevalence of sepsis in children, and biomarkers predicting outcomes are needed to guide prevention and treatment. We assessed the influence of DIC score on illness severity and mortality in children with suspected sepsis. Methods: This retrospective study used a clinical sepsis registry of pediatric patients presenting with suspected sepsis to the Emergency Department (ED) at Children's Hospital Colorado between April 1, 2012 and June 26, 2017. Exclusion criteria included: age <60 days or >18 years of age, transfer from another facility, and hospital length of stay (LOS) < 24 hours. Clinical data including age, gender, DIC score components (platelet count, fibrinogen, prothrombin time, D-dimer), use of vasopressors, mechanical ventilation, hospital and pediatric intensive care unit (PICU) length of stay, and presence of end-organ dysfunction as defined by the International Pediatric Sepsis Consensus Conference were extracted from the electronic medical record. In patients with multiple ED encounters, the first encounter with a full DIC evaluation was chosen for analysis. DIC scores were calculated based on the International Society of Thrombosis and Hemostasis (ISTH) criteria, with a score ≥ 5 indicating overt DIC. The influence of overt DIC on vasopressor use (primary outcome), 30-day mortality, and 1-year mortality were evaluated using univariate logistic regression. PICU and hospital LOS in those with and without overt DIC were compared using t-tests. Results : Of 1585 children with potential sepsis, 324 (20.4%) were fully evaluated for DIC within 24 hours; 47/324 (14.5%) were positive for overt DIC. Vasopressor use and mortality frequencies in each category are listed in Table 1. Patients evaluated for DIC were more ill than those who were not, with increased risk of vasopressor use, mortality, mechanical ventilation, end-organ dysfunction, and longer hospital and PICU length of stay (p < 0.005 for each). Among patients who had full DIC evaluations within 24 hours, children with overt DIC compared with those without had increased odds of vasopressor use (OR 2.52, 95% CI 1.34, 4.72, p=0.004), and 1-year mortality (OR 2.88, 95% CI 1.23, 6.77, p=0.014). The odds of death within 30 days of admission were insignificantly increased in overt DIC (OR 2.63, 95% CI 0.66, 10.55, p=0.17). Patients with overt DIC had longer average hospital length of stay (18 vs. 10 days, p=0.02) and PICU stay (7.5 vs. 4 days, p=0.03) compared to those with DIC scores < 5. Conclusions: Among pediatric patients with suspected sepsis, clinical assessment for DIC as well as laboratory confirmation of overt DIC are predictive of higher rates of vasopressor use, longer hospital and PICU lengths of stay, and increased 1 year mortality. These data suggest that the ISTH DIC score can be a valuable objective tool to predict risks for adverse outcomes in children presenting with suspected sepsis.

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