What is the management approach for Disseminated Intravascular Coagulation (DIC)?

Management of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is treating the underlying condition, followed by supportive care with blood products for bleeding, prophylactic anticoagulation for thrombotic risk, and regular clinical and laboratory monitoring. 1, 2

Diagnostic Approach

• Diagnosis requires both clinical assessment and laboratory testing
• Use ISTH scoring system based on:
  • Platelet count (<50 × 10^9/L indicates severe DIC)
  • Prolonged prothrombin time (PT/INR >1.1)
  • Fibrinogen levels (<1.5 g/L indicates severe consumption)
  • D-dimer (elevated >0.5 mg/L)
• Serial monitoring is essential as DIC is a dynamic process 2, 3

Management Algorithm

Step 1: Treat Underlying Cause (Primary Intervention)

• Immediate treatment of the underlying condition is the first-line strategy 1, 2
• Examples:
  • Cancer: Early initiation of chemotherapy
  • Acute promyelocytic leukemia: Immediate ATRA administration
  • Sepsis: Aggressive antimicrobial therapy and source control
  • Obstetric complications: Delivery or other appropriate interventions

Step 2: Classify DIC Type to Guide Treatment

• Procoagulant DIC (thrombosis predominant)
• Hyperfibrinolytic DIC (bleeding predominant)
• Subclinical DIC (laboratory abnormalities without overt symptoms)

Step 3: Supportive Care Based on DIC Type

For Bleeding-Predominant DIC:

1. Blood Component Therapy (only for active bleeding or high bleeding risk):

   • Platelets: Transfuse if count <50 × 10^9/L 2, 3
   • Fresh Frozen Plasma (FFP): 15-30 mL/kg for prolonged PT/aPTT 2, 3
   • Cryoprecipitate/Fibrinogen concentrate: If fibrinogen remains <1.5 g/L despite FFP 2, 3

2. Anticoagulation:

   • Generally avoid in active bleeding
   • Consider prophylactic anticoagulation when bleeding resolves 1

For Thrombosis-Predominant DIC:

1. Anticoagulation:

   • Therapeutic-dose anticoagulation for arterial/venous thrombosis 1
   • For severe cases (purpura fulminans, vascular skin infarction):
     • Consider unfractionated heparin (10 units/kg/h) without targeting specific aPTT 3
   • For non-bleeding patients:
     • Prophylactic LMWH or unfractionated heparin 1, 3

2. Blood Components:

   • Reserve for patients developing bleeding complications
   • Maintain higher platelet thresholds if invasive procedures needed

For All DIC Types:

• Regular Monitoring:
  • Clinical assessment for bleeding or thrombosis
  • Serial laboratory testing (platelets, PT/INR, fibrinogen, D-dimer)
  • Monitor for organ dysfunction 1, 2

Step 4: Special Considerations

• Avoid routine use of:

  • Tranexamic acid (except in hyperfibrinolytic DIC with therapy-resistant bleeding) 1
  • Recombinant Factor VIIa (carries thrombotic risks) 1, 2

• Central Line Management:

  • Prefer tunneled central venous catheters or implanted devices for long-term access
  • Use single-lumen catheters when possible
  • Place at compressible sites only
  • Correct coagulopathy before placement 2

Common Pitfalls to Avoid

• Delaying treatment of the underlying condition 2
• Transfusing blood products based solely on laboratory values without clinical bleeding 3
• Using antifibrinolytic agents without clear evidence of hyperfibrinolysis 1, 2
• Overlooking the short lifespan of transfused products in active DIC 2
• Misinterpreting normal coagulation screens (normal PT/aPTT does not exclude DIC) 2
• Failing to recognize a decreasing platelet trend as an early sign of DIC 2

Special Scenarios

• Severe thrombocytopenia with new thrombus: Consider platelet transfusion with therapeutic anticoagulation, or intermediate-dose anticoagulation without transfusion 1
• Need for inferior vena cava filter: Only consider temporary filter in patients who cannot receive anticoagulation but have proximal DVT likely to embolize 1