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Outcome of Early Hemostatic Intervention in Children With Sepsis and Nonovert Disseminated Intravascular Coagulation
Ahmed A El-Nawawy1, Mohamed I Elshinawy1, Doaa M Khater1,2
1Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
Insights
Early hemostatic management using plasma, heparin, and tranexamic acid in children with severe sepsis/septic shock significantly reduced mortality and progression to overt disseminated intravascular coagulopathy (DIC). This intervention in the pre-DIC stage offers a crucial "window of opportunity" for improved outcomes.
Area of Science:
- Pediatric critical care medicine
- Hematology
- Infectious diseases
Background:
- Severe sepsis and septic shock are leading causes of mortality in children.
- Disseminated intravascular coagulopathy (DIC) is a frequent and dangerous complication of sepsis.
- Early identification and management of coagulopathy in sepsis are critical for improving patient outcomes.
Purpose of the Study:
- To evaluate the effectiveness of early hemostatic management in preventing overt disseminated intravascular coagulopathy (DIC) in pediatric patients with severe sepsis/septic shock.
- To assess the impact of a specific intervention on mortality and progression to overt DIC.
- To determine if early intervention in the pre-DIC stage improves survival rates.
Main Methods:
- Prospective, open-label, randomized controlled clinical trial involving 80 pediatric patients with severe sepsis/septic shock in the non-overt DIC stage.
- Patients were randomized into two groups: one received a specific intervention (plasma transfusion, low-dose unfractionated heparin, tranexamic acid), and the control group did not.
- Comprehensive assessments included scoring systems (e.g., PIM-2, PELOD), laboratory tests, hemostatic markers (fibrin degradation products, d-dimers), and daily DIC risk assessment scores.
Main Results:
- The intervention group showed a significantly lower mortality rate compared to the control group.
- Progression to overt DIC was significantly less common in the intervention group (10%) versus the control group (45%).
- Higher DIC Risk Assessment Scores were observed in the control group on days 2 and 5, indicating more severe coagulopathy.
Conclusions:
- Early administration of fresh frozen plasma, low-dose heparin, and tranexamic acid in children with severe sepsis/septic shock, before overt DIC develops, is associated with improved survival and prevention of DIC progression.
- This therapeutic window offers a significant benefit without increasing bleeding risk.
- Larger multicenter studies are recommended to validate these findings and support widespread clinical adoption.
Objectives:
Evaluation of the outcome of early hemostatic management of disseminated intravascular coagulopathy in patients with severe sepsis/septic shock admitted to PICU, before the development of clinically overt disseminated intravascular coagulopathy.
Design:
Prospective interventional, open label randomized controlled clinical trial.
Setting:
PICU at Alexandria University Children's Hospital.
Patients:
The study included 80 patients with proven severe sepsis/septic shock in nonovert disseminated intravascular coagulopathy stage. They were randomly assigned into two groups (group 1 and group 2).
Interventions:
Specific intervention was applied for group 1 (plasma transfusion, low-dose unfractionated heparin, and tranexamic acid).
Measurements:
All patients had assessment of Pediatric Index of Mortality 2 score, Pediatric Logistic Organ Dysfunction score, inotropic score, routine laboratory, and hemostatic tests including fibrin degradation products and d-dimers. Disseminated intravascular coagulopathy risk assessment scores were calculated on daily basis.
Results:
Mortality rate was significantly higher in group 2. Progression to overt disseminated intravascular coagulopathy was significantly more common among group 2 patients than group 1 (45% and 10%, respectively) (p < 0.0001). Disseminated intravascular coagulopathyRisk Assessment Scores were significantly higher on the second and fifth days among group 2 patients. The initial specific hemostatic intervention was the only significant predictor of survival and prevention of progression to overt disseminated intravascular coagulopathy.
Conclusions:
Our results suggest that early use of a combination of fresh frozen plasma transfusion, low-dose heparin, and tranexamic acid in children with severe sepsis/septic shock in the "window of opportunity" before the development of overt disseminated intravascular coagulopathy stage was associated with better outcome for survival and prevention of progression to overt disseminated intravascular coagulopathy, with no increase in bleeding risk. Larger multicenter studies are needed to further prove this practice.
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