DIC resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Overview

Disseminated intravascular coagulation, is a pathological process in the body where the blood starts to coagulate throughout the whole body.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Disseminated intravascular coagulation in itself is a life-threatening condition and must be treated as such irrespective of the cause.

Common Causes

• Abruptio placentae
• Amniotic fluid embolism
• Aortic aneurysm
• Drugs (e.g. Amphetamines)
• Eclampsia
• Giant hemangioma
• HELLP syndrome
• Hemolytic transfusion reaction
• Malignancy (especially APL)
• Sepsis
• Severe allergic reaction
• Transplant rejection
• Trauma (e.g. Fat embolism, head injury)
• Venomous snake

Management

Below is an algorithm showing the initial approach to DIC.

Characterize the symptoms: ❑ Diffuse bleeding ❑ Jaundice ❑ Dyspnea ❑ Delirium ❑ Coma Obtain medical history: ❑ Prior thromboses ❑ Known hypercoagulability ❑ Known hemostatic defect

Examine the patient: ❑ Digital ischemia ❑ Hypotension ❑ Fever ❑ Acral cyanosis ❑ Bleeding from wounds/puncture sites ❑ Petechiae ❑ Purpura ❑ Ecchymosis ❑ Bedside Observations  :❑ Stroke  :❑ Acute MI  :❑ ARF  :❑ DVT  :❑ PE  :❑ Purpura fulminans

Consider alternative diagnosis: ❑ Severe liver disease ❑ TTP/HUS ❑ HIT

Order tests: ❑ Peripheral blood smear  :❑ ↓Platelet count < 100,000/mm³  :❑ + Schistocytes ❑ Clotting screen ❑ ↑PT ❑ ↑aPTT ❑ ↓Fibrinogen ❑ ↓Haptoglobin ❑ +D-dimer ❑ +FDP Other Investigations ❑ ↑ LDH ❑ ↓Factor V assay ❑ ↓Factor VIII assay ❑ ↓Protein C and Protein S ❑ ↓AT levels

Treatment

The goal of treatment of DIC is the treatment of the underlying disorder. Shown below is an algorithm for the general treatment of DIC.

Actively bleeding

Yes

No

Platelet transfusion if platelet count < 50,000/mm³

Fresh frozen plasma 15mg/kg initial dose or 6 units per 24 hours

Cryoprecipitate or Purified Fibrinogen concentrate

Assess for risk of VTE Severe purpura fulminans Acral ischemia or vascular skin infarction

High risk

Yes

No

Unfractionated heparin 10 micron/kg/hr or 300-500U per hour continuous infusion

Low Molecular Weight Heparin

Assess for severe sepsis

Yes

No

Antithrombin III

Recombinant human activated Protein C Continuous infusion 24 microgram/kg/hr for 4days

Do's

• The transfusion of platelets should be considered for those patients actively bleeding or at an increased risk of bleeding with a platelet count of less than 50,000 microliter.
• Fibrinogen level should be kept at a level greater than 100mg/dl
• Therapy with heparin used generally for patients with low grade DIC having predominantly thrombotic episodes such as acral ischemia and thrombophlebitis.

Dont's

• Do not transfuse platelets or plasma based primarily on laboratory results but should generally be for patients who are bleeding.
• Don't give recombinant human activated protein C to patients with increased risk of bleeding.
• Don't give recombinant human activated protein C to patients with platelet counts < 30,000 microliter.
• Avoid the intravenous bolus injection of heparin of 50,000-10,000 units.