What is the management of disseminated intravascular coagulation (DIC) in sepsis?

Management of Disseminated Intravascular Coagulation (DIC) in Sepsis

The cornerstone of DIC management in sepsis is treating the underlying infection while implementing a two-step diagnostic approach to identify candidates for anticoagulant therapy based on sepsis-induced coagulopathy (SIC) and overt DIC criteria. 1

Diagnostic Approach

Step 1: Screen for Sepsis-Induced Coagulopathy (SIC)

• For septic patients with thrombocytopenia (platelet count <150 × 10^9/L), apply the SIC scoring system:

Parameter	Score	Criteria
Platelet count (×10^9/L)	2	<100
	1	≥100, <150
PT ratio	2	>1.4
	1	>1.2, ≤1.4
SOFA score	2	≥2

• SIC diagnosis: Total score ≥4 2, 1

Step 2: Evaluate for Overt DIC

If SIC criteria are met, proceed to evaluate for overt DIC:

Parameter	Score	Criteria
Platelet count (×10^9/L)	2	<50
	1	≥50, <100
FDP/D-dimer	3	Strong increase
	2	Moderate increase
PT	2	≥6 seconds prolonged
	1	≥3, <6 seconds prolonged
Fibrinogen (g/mL)	1	<100

• Overt DIC diagnosis: Total score ≥5 2, 1

Treatment Algorithm

1. Control the underlying infection

   • Appropriate antimicrobial therapy
   • Source control measures (drainage, debridement, etc.)

2. Supportive care

   • Maintain organ perfusion
   • Hemodynamic support
   • Ventilatory support if needed

3. Anticoagulant therapy (based on SIC/DIC scoring)

   • Consider for patients with SIC score ≥4 and PT-INR ≥1.5 3

   • Options include:

     a. Antithrombin

     • May be considered in septic patients with DIC 1
     • Most beneficial when not combined with heparin 1

     b. Recombinant thrombomodulin

     • May be used in countries where licensed 1
     • Less effective if protein C levels are severely reduced due to hepatic dysfunction 1
     • In a subanalysis, showed lower mortality (21.4%) compared to heparin (31.6%) in sepsis cases 2

     c. Heparin therapy

     • Unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH)
     • Not contraindicated in DIC due to sepsis 4
     • May help prevent purpura fulminans and symmetrical peripheral gangrene 1

4. Blood component therapy

   • Reserve for active bleeding or planned invasive procedures
   • Platelet transfusion if count <20,000/μL with bleeding or <50,000/μL before invasive procedures
   • Fresh frozen plasma if prolonged PT/INR with bleeding
   • Cryoprecipitate if fibrinogen <100 mg/dL with bleeding

Monitoring and Follow-up

• Daily assessment of coagulation parameters (platelet count, PT/INR, fibrinogen, D-dimer)
• Monitor for bleeding complications
• Reassess SIC and DIC scores to guide ongoing therapy
• Consider endothelium-related biomarkers for early detection of DIC progression 1

Special Considerations

• Symmetrical peripheral gangrene (SPG): A devastating complication of sepsis and DIC causing distal extremity limb loss. Early anticoagulation with heparin and antithrombin might reduce this risk 2, 1

• Differential diagnosis: Important to distinguish DIC from other thrombocytopenic conditions such as thrombotic thrombocytopenic purpura (TTP) and heparin-induced thrombocytopenia (HIT) 5

• Hepatic dysfunction: May reduce protein C levels, potentially limiting the effectiveness of recombinant thrombomodulin therapy 1

Common Pitfalls to Avoid

• Delaying treatment of the underlying infection
• Treating all septic patients with anticoagulants without appropriate SIC/DIC scoring
• Focusing solely on laboratory values without clinical correlation
• Inappropriate use of blood products in non-bleeding patients
• Failing to reassess coagulation parameters regularly

The early identification of sepsis-induced coagulopathy using the SIC criteria, followed by appropriate management of the underlying infection and targeted anticoagulant therapy, offers the best chance for improving outcomes in patients with sepsis-associated DIC.