How to manage disseminated intravascular coagulation (DIC) in patients with a dialysis catheter?

Management of Disseminated Intravascular Coagulation (DIC) in Patients with Dialysis Catheters

For patients with disseminated intravascular coagulation (DIC) and dialysis catheters, treatment should focus on addressing the underlying cause of DIC while maintaining catheter function and preventing complications through careful site management, appropriate coagulation correction, and consideration of catheter exchange or removal in cases of infection. 1, 2

Assessment and Diagnosis of DIC

• Diagnose DIC using the International Society on Thrombosis and Haemostasis (ISTH) scoring system based on:

  • Platelet count
  • Prolonged prothrombin time (PT/INR)
  • Fibrinogen levels
  • D-dimer or fibrin degradation products (FDPs) 1, 2

• Monitor coagulation parameters serially as DIC is a dynamic process 2

  • A 30% drop in platelet count may indicate subclinical DIC
  • Normal PT/aPTT does not exclude DIC, especially in subclinical forms

• Recognize the clinical presentation pattern:

  • Procoagulant DIC: Thrombosis predominates (common in solid tumors)
  • Hyperfibrinolytic DIC: Bleeding predominates (common in acute leukemias)
  • Subclinical DIC: Laboratory abnormalities without obvious clinical manifestations 1, 2

Catheter Site Management in DIC

1. Monitor catheter sites visually when changing dressings or by palpation through intact dressings 1

   • Remove dressing for thorough examination if patients have:
     • Tenderness at insertion site
     • Fever without obvious source
     • Other manifestations suggesting infection

2. Replace catheter site dressings:

   • Every 2 days for gauze dressings
   • At least every 7 days for transparent dressings
   • Immediately if dressing becomes damp, loosened, or visibly soiled 1

3. Use chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months if CLABSI rates remain high despite basic prevention measures 1

4. Use povidone-iodine antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after insertion and after each dialysis session 1

Management of Coagulopathy in Patients with Dialysis Catheters and DIC

1. Treat the underlying cause of DIC as the cornerstone of management 1, 2, 3

2. For patients with bleeding or at high risk of bleeding (e.g., prior to catheter placement or exchange):

   • Transfuse platelets if count is <50 × 10^9/L 1, 3
   • Administer fresh frozen plasma (FFP) for prolonged PT and aPTT in actively bleeding patients 3
   • Consider fibrinogen replacement (cryoprecipitate or fibrinogen concentrate) for severe hypofibrinogenemia (<1 g/L) that persists despite FFP 3

3. For patients with thrombosis-predominant DIC:

   • Use therapeutic doses of heparin for:
     • Arterial or venous thromboembolism
     • Severe purpura fulminans with acral ischemia
     • Vascular skin infarction 1, 3
   • Consider continuous infusion of unfractionated heparin (UFH) at weight-adjusted doses (e.g., 10 μ/kg/h) if there is a co-existing high risk of bleeding 3

4. For non-bleeding patients with DIC:

   • Provide prophylaxis for venous thromboembolism with prophylactic doses of heparin or low molecular weight heparin 3

Catheter Management in DIC

1. For new catheter placement in DIC patients:

   • Choose compressible sites for central venous access (internal jugular preferred) 2
   • Use ultrasound guidance to reduce complications 2
   • Correct coagulopathy prior to the procedure 2
   • Ensure catheter tip placement at the junction of superior vena cava and right atrium 2

2. For catheter-related bloodstream infection (CRBSI) in DIC patients:

   • Obtain appropriate cultures prior to initiating empiric antibiotics 1
   • Consider individualized approach based on patient's circumstances:
     • Catheter exchange via guidewire
     • Catheter removal and reinsertion
     • Catheter salvage with antibiotic lock therapy 1

3. For CRBSI due to specific pathogens:

   • Remove catheter for S. aureus and Candida species infections 1
   • For coagulase-negative staphylococci or gram-negative bacilli:
     • Consider catheter retention with antibiotic lock therapy for 3 weeks
     • Or exchange catheter over guidewire followed by antibiotic course 1

4. For antibiotic lock therapy (when catheter salvage is the goal):

   • Use in conjunction with systemic antimicrobial therapy for 10-14 days
   • Ensure dwell times do not exceed 48 hours before reinstallation
   • For hemodialysis patients, renew lock solution after every dialysis session 1

Special Considerations and Pitfalls

• Avoid routine use of anticoagulant therapy to reduce catheter-related infection risk in general patient populations 1

• Do not routinely replace CVCs, PICCs, or hemodialysis catheters to prevent catheter-related infections 1

• Be aware that transfused platelets and fibrinogen may have very short lifespans in DIC due to ongoing consumption 2

• Recognize that the success rate of antibiotic lock therapy varies by pathogen:

  • 87-100% for gram-negative pathogens
  • 75-84% for S. epidermidis
  • Only 40-55% for S. aureus 1

• For long-term access in DIC patients, tunneled CVCs or totally implanted devices are preferred over PICCs due to lower thrombosis risk 2