From the Guidelines
Management of suspected occult Disseminated Intravascular Coagulation (DIC) should prioritize addressing the underlying cause and supportive care with blood component therapy, as outlined in the most recent guidance from the SSC of the ISTH 1. The approach to managing suspected occult DIC involves a combination of laboratory evaluation and therapeutic interventions. Key laboratory tests include complete blood count, coagulation studies (PT, PTT, fibrinogen, D-dimer), and organ function tests.
- The cornerstone of treatment is addressing the underlying cause, such as infection, trauma, or malignancy.
- Supportive care includes:
- Blood component therapy with platelets (for counts <50,000/μL with bleeding or <20,000/μL without bleeding) 1.
- Fresh frozen plasma (15–30 mL kg-1) for significant coagulopathy, with careful clinical monitoring to decide on dose adjustments 1.
- Cryoprecipitate (two pools or fibrinogen concentrate) if fibrinogen levels fall below 1.5 g L-1 despite supportive measures 1.
- Anticoagulation with unfractionated heparin may be considered in cases with predominant thrombosis, though this remains controversial and should be approached with caution, considering the risk of bleeding 1.
- Serial monitoring of coagulation parameters every 6-8 hours is essential to guide therapy, as the lifespan of transfused platelets and fibrinogen may be very short, especially in patients with vigorous coagulation activation and fibrinolysis 1.
- The use of antifibrinolytic agents, such as tranexamic acid, is not routinely recommended and may be deleterious in non-hyperfibrinolytic DIC 1.
- Recombinant FVIIa is not recommended due to uncertain benefits and associated thrombotic risks 1. The primary goal is to interrupt the pathological activation of coagulation while supporting hemostasis until the underlying condition can be controlled, as DIC represents a consumptive coagulopathy resulting from excessive thrombin generation, fibrin deposition, and subsequent fibrinolysis 1.
From the Research
Management Approach for Suspected Occult Disseminated Intravascular Coagulation (DIC)
The management of suspected occult DIC involves a comprehensive approach that includes both clinical and laboratory evaluations.
- The diagnosis of DIC should encompass both clinical and laboratory information, utilizing tools such as the International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system 2.
- Treatment of the underlying condition is the cornerstone of managing DIC, with supportive care tailored to the individual patient's needs and laboratory results 2, 3.
- Transfusion of platelets or plasma components in patients with DIC should not be based solely on laboratory results but should be considered for patients who present with bleeding or are at high risk of bleeding 2, 4.
Transfusion Considerations
- In patients with DIC and bleeding, or at high risk of bleeding, transfusion of platelets should be considered if the platelet count is <50 x 10(9)/l 2.
- Administration of fresh frozen plasma (FFP) may be useful in bleeding patients with DIC and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) 2.
- Severe hypofibrinogenemia (<1 g/l) that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate 2.
Anticoagulation and Thrombosis
- In cases of DIC where thrombosis predominates, therapeutic doses of heparin should be considered, with careful monitoring for signs of bleeding 2.
- Prophylaxis for venous thromboembolism with prophylactic doses of heparin or low molecular weight heparin is recommended in critically ill, non-bleeding patients with DIC 2.
Specific Patient Considerations
- Patients with severe sepsis and DIC may benefit from treatment with recombinant human activated protein C, although this should be avoided in patients at high risk of bleeding 2.
- The use of antifibrinolytic agents is generally not recommended in patients with DIC, except in cases of primary hyperfibrinolytic state with severe bleeding 2.