From the Guidelines
Disseminated Intravascular Coagulation (DIC) should be suspected in any patient presenting with unexplained bleeding or clotting abnormalities, particularly in the context of known triggering conditions, such as sepsis, major trauma, or malignancy, as identified in the most recent guidance from the International Society on Thrombosis and Haemostasis 1.
Common Clinical Scenarios
Common clinical scenarios that should raise suspicion for DIC include:
- Patients with sepsis
- Major trauma
- Obstetric complications, especially placental abruption, amniotic fluid embolism, or postpartum hemorrhage
- Malignancy, particularly acute promyelocytic leukemia
- Severe burns
- Major surgery
Laboratory Findings
Laboratory findings that suggest DIC include:
- Thrombocytopenia
- Prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT)
- Decreased fibrinogen levels
- Elevated D-dimer or fibrin degradation products The combination of these abnormalities, rather than any single test, is most diagnostic, as noted in recent studies on sepsis-induced coagulopathy 1.
Importance of Early Recognition
Clinicians should be particularly vigilant for DIC when patients develop multiorgan dysfunction, as microvascular thrombosis can lead to organ failure. Early recognition is critical because DIC carries high mortality, and prompt treatment of the underlying condition along with supportive care (including blood product replacement as needed) can improve outcomes, as emphasized in the management of cancer-associated DIC 1 and sepsis-induced coagulopathy 1. The pathophysiology involves widespread activation of coagulation pathways, leading to simultaneous thrombosis and hemorrhage as clotting factors and platelets become depleted.
Recent Guidance and Recommendations
Recent guidance from the International Society on Thrombosis and Haemostasis highlights the importance of early detection and management of sepsis-induced coagulopathy and DIC, with recommendations for screening and diagnostic criteria 1. The use of biomarkers, such as D-dimer and fibrinogen, can aid in the early detection of DIC, as discussed in the context of COVID-19 1 and cancer-associated DIC 1.
From the Research
When to Suspect Disseminated Intravascular Coagulation (DIC)
DIC should be suspected in patients with underlying disorders that can trigger the systemic activation of coagulation, such as:
- Severe infection (sepsis) 2, 3
- Solid tumors or hematological neoplasia 2, 3
- Pregnancy complications 2, 3
- Vascular diseases (e.g., aortic diseases) 2, 3
- Trauma 2, 3
- Newborn complications 2
- Tissue damage due to internal or external insults 2
- Exposure to chemical or biological agents 2
Clinical Presentations
Patients with DIC may present with:
- Bleeding manifestations (e.g., purpura, petechiae, bleeding from invasive sites) 4, 5, 6, 3
- Organ failure (e.g., acute kidney injury, respiratory failure) 4, 5, 6, 3
- Thrombotic events (e.g., deep vein thrombosis, pulmonary embolism) 4, 5, 6
Laboratory Findings
The diagnosis of DIC is supported by laboratory findings, including:
- Prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) 4, 5, 6
- Low platelet count (<50 x 10^9/L) 4, 5, 6
- Low fibrinogen level (<1 g/L) 4, 5, 6
- Elevated D-dimer, fibrin(ogen) split products (FSP), and soluble fibrin monomer (FM) 6
Diagnostic Approach
The International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system provides an objective measurement of DIC 4. The diagnosis should encompass both clinical and laboratory information, and tests should be repeated to monitor the dynamically changing scenario based on laboratory results and clinical observations 4.