What is the management of Disseminated Intravascular Coagulation (DIC)?

Management of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is treating the underlying cause while providing supportive care based on clinical presentation, with specific blood product replacement guided by laboratory parameters and bleeding status. 1

Diagnostic Evaluation

• Confirm DIC diagnosis using the International Society on Thrombosis and Haemostasis (ISTH) scoring system based on:
  • Platelet count (normal: 150-450 × 10^9/L; DIC: <50 × 10^9/L)
  • Prothrombin time (normal: 11-14 seconds; DIC: >14 seconds)
  • Fibrinogen (normal: 2-4 g/L; DIC: <1.5 g/L)
  • D-dimer (normal: <0.5 mg/L; DIC: >0.5 mg/L) 1
• Perform serial laboratory testing to monitor progression

Treatment Algorithm

Step 1: Treat Underlying Cause

• Identify and aggressively treat the underlying condition (sepsis, trauma, malignancy, obstetric complications) 1, 2
• This is the most critical intervention for resolving DIC

Step 2: Supportive Blood Product Management

For bleeding patients or high bleeding risk:

• Platelet transfusion:
  • Maintain platelet count >50 × 10^9/L if actively bleeding
  • Lower threshold of 20-30 × 10^9/L acceptable in non-bleeding DIC 1, 2
• Fresh Frozen Plasma (FFP):
  • Administer 15-30 mL/kg for patients with prolonged PT/PTT and active bleeding
  • Do not base transfusion solely on laboratory values 1, 2
• Fibrinogen replacement:
  • Consider fibrinogen concentrate or cryoprecipitate if fibrinogen remains <1.5 g/L despite FFP 1

For non-bleeding patients:

• Avoid prophylactic platelet transfusion unless high bleeding risk
• Avoid unnecessary correction of laboratory abnormalities without clinical bleeding 1, 2

Step 3: Anticoagulation Management

• For thrombosis-predominant DIC (purpura fulminans, vascular skin infarction, arterial/venous thromboembolism):

  • Administer therapeutic heparin (weight-adjusted continuous infusion) 1, 2
  • Consider low-dose unfractionated heparin (10 units/kg/hr) if bleeding risk is high 2

• For non-bleeding patients with DIC:

  • Provide thromboprophylaxis with low-molecular-weight heparin until bleeding occurs or platelet count drops below 30 × 10^9/L 1, 3

• Heparin is specifically indicated in DIC for:

  • FDA-approved indication for treatment of acute and chronic consumptive coagulopathies (DIC) 4
  • Retained dead fetus with hypofibrinogenemia
  • DIC associated with malignancy, particularly promyelocytic leukemia 5

Step 4: Advanced Therapies

• Consider recombinant human activated protein C for severe sepsis with DIC (24 μg/kg/h for 4 days)
  • Contraindicated in patients with platelet counts <30 × 10^9/L or high bleeding risk 2

Special Considerations

• Central line placement in DIC patients:

  • Choose compressible sites only
  • Correct coagulopathy prior to procedure
  • Use tunneled central venous catheters for long-term access
  • Prefer single-lumen over multi-lumen catheters 1

• Antifibrinolytic therapy:

  • Generally not recommended in DIC
  • Consider only in primary hyperfibrinolytic DIC with severe bleeding (tranexamic acid 1g every 8h) 2

Common Pitfalls to Avoid

1. Overlooking the short lifespan of transfused products in active DIC
2. Using antifibrinolytic agents without clear indication of hyperfibrinolytic DIC
3. Using recombinant Factor VIIa, which carries thrombotic risks
4. Delaying treatment of the underlying disease
5. Misinterpreting normal coagulation screens (normal PT/aPTT does not exclude DIC) 1
6. Administering prophylactic platelet transfusions in non-bleeding patients, which may worsen disseminated thrombosis 1

Monitoring

• Perform regular monitoring of blood counts and coagulation parameters
• Visually inspect central line sites when changing dressings
• Monitor for signs of bleeding or thrombosis
• Repeat DIC scoring to assess response to treatment 1