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

Diagnosis and Treatment of Disseminated Intravascular Coagulation (DIC)

The treatment of Disseminated Intravascular Coagulation (DIC) must prioritize addressing the underlying condition causing DIC, followed by supportive care with blood products for bleeding, and in specific cases, anticoagulation with heparin when thrombosis predominates. 1, 2

Signs and Symptoms of DIC

DIC presents with two major clinical manifestations:

1. Hemorrhagic manifestations:

   • Oozing from multiple sites
   • Difficult-to-control bleeding
   • Petechiae and purpura
   • Bleeding from venipuncture sites
   • Mucosal bleeding

2. Thrombotic manifestations:

   • Acral ischemia (digits, nose, ears)
   • Vascular skin infarction
   • Organ dysfunction due to microvascular thrombosis
   • Arterial or venous thromboembolism

Diagnostic Approach

Laboratory evaluation should include:

• Complete PT/PTT panel with specific factor assays
• Platelet count (typically <50 × 10^9/L in DIC)
• Fibrinogen level (typically <1.5 g/L in DIC)
• D-dimer (elevated >0.5 mg/L)
• Serial testing to monitor dynamic changes 1

The International Society on Thrombosis and Haemostasis (ISTH) scoring system provides objective measurement of DIC severity and should be used to guide management decisions 3.

Treatment Algorithm for DIC

1. Treat the Underlying Cause

• This is the cornerstone of DIC management 1, 3
• Common causes include sepsis, trauma, malignancies, and obstetric complications

2. Supportive Care with Blood Products (for bleeding manifestations)

• Platelet transfusion:

  • For patients with active bleeding and platelet count <50 × 10^9/L
  • Not recommended prophylactically in non-bleeding patients unless high risk of bleeding 1, 3

• Fresh Frozen Plasma (FFP):

  • Administer 15 ml/kg for significant bleeding or before invasive procedures
  • Not based solely on laboratory results 1, 3
  • Consider factor concentrates if fluid overload is a concern

• Fibrinogen replacement:

  • Consider cryoprecipitate if fibrinogen <1 g/L despite FFP 1, 3

3. Anticoagulation (for thrombotic manifestations)

• Heparin therapy:

  • Indicated when thrombosis predominates (arterial/venous thromboembolism, purpura fulminans, vascular skin infarction) 3
  • Continuous infusion unfractionated heparin (UFH) at 10 units/kg/hr is preferred due to short half-life and reversibility 3
  • For treatment of acute and chronic consumptive coagulopathies (DIC) 2
  • Dosing:
    • Initial: 5,000 units IV followed by continuous infusion of 20,000-40,000 units/24 hours 2
    • Monitor based on clinical response rather than targeting specific aPTT values 3

• Prophylactic anticoagulation:

  • Low molecular weight heparin or unfractionated heparin at prophylactic doses recommended for critically ill, non-bleeding DIC patients 3

4. Special Considerations

• Antifibrinolytic agents (e.g., tranexamic acid):

  • Generally contraindicated in DIC
  • Exception: Primary hyperfibrinolytic state with severe bleeding (1g every 8 hours) 3

• Recombinant human activated protein C:

  • May be considered in severe sepsis with DIC (24 μg/kg/h for 4 days)
  • Contraindicated in patients at high risk of bleeding or platelet counts <30 × 10^9/L 3

• Antithrombin concentrate:

  • Not routinely recommended based on current evidence 3

Common Pitfalls and Caveats

• Relying solely on INR for non-warfarin patients can be misleading 1
• Overlooking the short lifespan of transfused products in active DIC 1
• Using antifibrinolytic agents without clear indication of hyperfibrinolytic DIC 1
• Using recombinant Factor VIIa without evidence in DIC 1
• Delaying treatment of the underlying disease 1
• Misinterpreting normal coagulation screens, as normal PT/aPTT does not exclude DIC 1
• Administering blood products based solely on laboratory values rather than clinical bleeding 3

Monitoring and Follow-up

• Repeat laboratory tests frequently to monitor the dynamic changes in coagulation parameters
• Adjust therapy based on clinical response and laboratory trends
• Continue treatment until resolution of the underlying condition and normalization of coagulation parameters

The management of DIC requires a balanced approach that addresses both bleeding and thrombotic risks while treating the underlying cause. Early recognition and prompt intervention are essential to improve outcomes in this complex and potentially life-threatening condition.