DIC resident survival guide: Difference between revisions

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==Overview==
==Overview==
Disseminated intravascular coagulation, is a [[pathology|pathological]] process in the body where the [[blood]] starts to [[coagulation|coagulate]] throughout the whole body. This depletes the body of its [[platelet]]s and coagulation factors, and there is a paradoxically increased risk of [[hemorrhage]].
Disseminated intravascular coagulation, is a [[pathology|pathological]] process in the body where the [[blood]] starts to [[coagulation|coagulate]] throughout the whole body.


==Causes==
==Causes==
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Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.  
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 causes.
Disseminated intravascular coagulation in itself is a life-threatening condition and must be treated as such irrespective of the cause.


===Common Causes===
===Common Causes===
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*[[Drugs]] (e.g. [[Amphetamines]])
*[[Drugs]] (e.g. [[Amphetamines]])
*[[Eclampsia]]
*[[Eclampsia]]
*[[Giant hemangioma]]
*[[hemangioma|Giant hemangioma]]
*[[HELLP syndrome]]
*[[HELLP syndrome]]
*Hemolytic transfusion reaction
*[[transfusion reaction|Hemolytic transfusion reaction]]
*[[Malignancy]] (especially [[APL]])
*[[Malignancy]] (especially [[APL]])
*[[Sepsis]]
*[[Sepsis]]
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==Management==
==Management==
Below is an algorithm showing the initial approach to [[DIC]].
{{familytree/start}}
{{familytree | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ Diffuse bleeding <br>❑ [[Jaundice]] <br> ❑ [[Dyspnea]] <br> ❑ [[Delirium]] <br> ❑ [[Coma]]
----
'''Obtain medical history:''' <br> ❑ Prior thromboses <br> ❑ Known hypercoagulability <br> ❑ Known hemostatic defect</div>}}
{{familytree | | | | |!| | }}
{{familytree | | | | B01 | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> ❑ Digital ischemia <br> ❑ [[Hypotension]] <br> ❑ [[Fever]] <br> ❑ [[acrocyanosis|Acral cyanosis]] <br> ❑ Bleeding from wounds/puncture sites <br> ❑ [[Petechiae]] <br> ❑ [[Purpura]] <br> ❑ [[Ecchymosis]] <br> ❑ Bedside Observations <br> :❑ [[Stroke]] <br> :❑ [[Acute MI]] <br> :❑ [[ARF]] <br> :❑ [[DVT]] <br> :❑ [[PE]] <br> :❑ [[Purpura fulminans]] </div>}}
{{familytree | | | | |!| | }}
{{familytree | | | | C01 | |C01=<div style="float: left; text-align: left; line-height: 150% "> '''Consider alternative diagnosis:''' <br> ❑ [[liver disease|Severe liver disease]] <br> ❑ [[TTP]]/[[HUS]] <br> ❑ [[HIT]]</div>}}
{{familytree | | | | |!| | }}
{{familytree | | | | D01 | |D01= <div style="float: left; text-align: left; line-height: 150% "> '''Order tests:'''<br> ❑ [[Peripheral blood smear]] <br> :❑ ↓[[Platelet count]] < 100,000/mm³ <br> :❑ + [[Schistocytes]] <br> ❑ Clotting screen <br>
:❑ ↑[[PT]] <br>
:❑ ↑[[aPTT]] <br>
:❑ ↓[[Fibrinogen]] <br>
:❑ ↓[[Haptoglobin]] <br>
:❑ +[[D-dimer]] <br>
:❑ +[[FDP]]
----
'''Other Investigations''' <br> ❑ ↑ [[LDH]] <br> ❑ ↓Factor V assay <br> ❑ ↓Factor VIII assay <br> ❑ ↓[[Protein C]] and [[Protein S]] <br> ❑ ↓AT levels </div>}}
{{familytree/end}}
===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.
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | |A01=}}
{{familytree | | | | | | | | | | | A01 | | | | |A01= Actively bleeding}}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|.| | |}}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|.| | |}}
{{familytree | | | | | | B01 | | | | | | B02 | |B01=|B02=}}
{{familytree | | | | | | B01 | | | | | | B02 | |B01= Yes|B02= No}}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | |!| | | |}}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | |!| | | |}}
{{familytree | | C01 | | C02 | | C03 | | C04 | | | | |C01=|C02=|C03=|C04=}}
{{familytree | | C01 | | C02 | | C03 | | C04 | | | | |C01= Platelet transfusion <br> if platelet count < 50,000/mm³|C02= Fresh frozen plasma <br> 15mg/kg initial dose or <br> 6 units per 24 hours|C03= Cryoprecipitate or <br> Purified Fibrinogen concentrate|C04= Assess for risk of VTE <br> Severe purpura fulminans <br> Acral ischemia or vascular skin infarction}}
{{familytree | | | | | | | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | | | | D01 | | | |D01=}}
{{familytree | | | | | | | | | | | | | | D01 | | | |D01= High risk}}
{{familytree | | | | | | | | | | | |,|-|-|^|-|-|.| | |}}
{{familytree | | | | | | | | | | | |,|-|-|^|-|-|.| | |}}
{{familytree | | | | | | | | | | | E01 | | | | E02 | | |E01=|E02=}}
{{familytree | | | | | | | | | | | E01 | | | | E02 | | |E01= Yes|E02= No}}
{{familytree | | | | | | | | | |,|-|^|-|.| | | |!| | |}}
{{familytree | | | | | | | | | |,|-|^|-|.| | | |!| | |}}
{{familytree | | | | | | | | | F01 | | F02 | | F03 | | |F01=|F02=|F03=}}
{{familytree | | | | | | | | | F01 | | F02 | | F03 | | |F01= Unfractionated heparin <br> 10 micron/kg/hr or <br> 300-500U per hour continuous infusion|F02= Low Molecular Weight Heparin|F03= Assess for severe sepsis}}
{{familytree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | | | | | | | | | | G01 | | G02 | |G01=|G02=}}
{{familytree | | | | | | | | | | | | | | | G01 | | G02 | |G01= Yes|G02= No}}
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | | | | | | | | H01 | | H02 | |H01=|H02=}}
{{familytree | | | | | | | | | | | | | H01 | | H02 | |H01= Antithrombin III|H02= Recombinant human activated Protein C <br> Continuous infusion 24 microgram/kg/hr for 4days}}
{{familytree/end}}
{{familytree/end}}



Latest revision as of 00:26, 13 March 2014

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

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.[1]
  • 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.[1]
  • Don't give recombinant human activated protein C to patients with increased risk of bleeding.[1]
  • Don't give recombinant human activated protein C to patients with platelet counts < 30,000 microliter.[1]
  • Avoid the intravenous bolus injection of heparin of 50,000-10,000 units.

References

  1. 1.0 1.1 1.2 1.3 Levi M, Toh CH, Thachil J, Watson HG (2009). "Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology". Br J Haematol. 145 (1): 24–33. doi:10.1111/j.1365-2141.2009.07600.x. PMID 19222477.

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