What is the approach to Disseminated Intravascular Coagulation (DIC) in a patient in the Intensive Care Unit (ICU) with lactic acidosis?

From the Guidelines

The management of Disseminated Intravascular Coagulation (DIC) in ICU patients with lactic acidosis requires aggressive treatment of the underlying cause while providing supportive care for coagulation abnormalities, with a focus on early detection and intervention as suggested by the ISTH DIC SSC and Perioperative and Critical Care SSC 1.

Key Considerations

• Identify and treat the precipitating condition, which may include sepsis, trauma, malignancy, or obstetric complications.
• For patients with active bleeding, provide blood product support with platelets (target >50,000/μL), fresh frozen plasma (10-15 mL/kg), or cryoprecipitate (target fibrinogen >100-150 mg/dL) as needed based on laboratory values, as recommended by the ACC and ASH guidelines 1.
• For severe bleeding, consider tranexamic acid (1g IV over 10 minutes, followed by 1g over 8 hours) to inhibit fibrinolysis.
• Simultaneously address the lactic acidosis by ensuring adequate tissue perfusion with IV crystalloids (30 mL/kg bolus initially for septic shock), vasopressors if needed (norepinephrine starting at 0.05-0.1 mcg/kg/min), and optimizing oxygen delivery, following the principles outlined in the Surviving Sepsis Campaign guidelines 1.

Monitoring and Adjustments

• Monitor coagulation parameters (PT, PTT, fibrinogen, D-dimer) and lactate levels frequently, typically every 4-6 hours initially.
• In non-bleeding patients with laboratory evidence of DIC, blood products may be withheld unless invasive procedures are planned or platelet counts fall below 10,000-20,000/μL.
• Anticoagulation with heparin (unfractionated at 10-15 units/kg/hr without bolus) may be considered in cases with predominant thrombosis, particularly in cancer-associated DIC.
• Continuous renal replacement therapy may help manage severe acidosis refractory to other interventions.

Prioritization of Care

• The approach should prioritize the management of both coagulopathy and metabolic derangements while targeting the primary disease process, with a focus on reducing morbidity, mortality, and improving quality of life.
• The use of sodium bicarbonate therapy is not recommended for the treatment of hypoperfusion-induced lactic acidemia with pH ≥ 7.15, as stated in the Surviving Sepsis Campaign guidelines 1.

From the Research

Approach to DIC for Patient in the ICU with Lactic Acidosis

• The approach to Disseminated Intravascular Coagulation (DIC) in patients in the Intensive Care Unit (ICU) with lactic acidosis involves treating the underlying cause of the condition, as stated in 2.
• Lactic acidosis is a common condition encountered by critical care providers, and its treatment continues to be aimed at the underlying source, as mentioned in 3.

Management and Treatment

• The management of lactic acidosis in the ICU involves identifying and addressing the underlying cause, which may include sepsis, tissue hypoxia, or other conditions, as discussed in 4 and 5.
• Treatment of anion gap acidosis, which includes lactic acidosis, is aimed at the underlying disease or removal of the toxin, as stated in 4.
• The use of therapy to normalize the pH is controversial, and treatment should focus on addressing the underlying cause, as mentioned in 4.
• In patients with DIC, treatment strategies aim to control activation of blood coagulation and bleeding risk, as discussed in 2.
• Therapeutic strategies for DIC may include antithrombin, activated protein C, tissue factor pathway inhibitor, and thrombomodulin, although the efficacy and safety of these treatments are still being studied, as mentioned in 2.