What are the guidelines for administering blood products and monitoring in Disseminated Intravascular Coagulation (DIC) management in the Intensive Care Unit (ICU)?

Management of Disseminated Intravascular Coagulation (DIC) in the ICU

The management of DIC in the ICU requires targeted blood product administration based on laboratory parameters, with platelet transfusions for counts <50 × 10^9/L in bleeding patients, fresh frozen plasma (15 ml/kg) for significant bleeding or prolonged PT/PTT, and fibrinogen replacement with cryoprecipitate when levels are <1 g/L. 1

Diagnosis and Monitoring

DIC diagnosis should be based on both clinical presentation and laboratory parameters, using the International Society on Thrombosis and Haemostasis (ISTH) scoring system:

• Essential laboratory tests for diagnosis and monitoring:

  • Platelet count (normal: 150-450 × 10^9/L; DIC: <50 × 10^9/L)
  • Prothrombin time/INR (normal: 11-14 seconds/0.9-1.1; DIC: >14 seconds/>1.1)
  • Fibrinogen (normal: 2-4 g/L; DIC: <1.5 g/L)
  • D-dimer (normal: <0.5 mg/L; DIC: >0.5 mg/L) 1, 2

• Serial monitoring is crucial as DIC is a dynamic process with rapidly changing parameters 1, 2

• Additional useful tests: antithrombin activity and von Willebrand factor (biomarkers for endothelial injury) 1

Blood Product Administration Guidelines

Platelet Transfusion

• For patients with active bleeding: Transfuse when platelet count <50 × 10^9/L
• For non-bleeding patients at high risk (e.g., pre-procedure): Consider transfusion when count <20-30 × 10^9/L
• For non-bleeding patients without high risk: Prophylactic transfusion not recommended 1, 2

Fresh Frozen Plasma (FFP)

• Dosage: 15 ml/kg (may range up to 30 ml/kg for urgent invasive procedures)
• Indications:
  • Active bleeding with prolonged PT/PTT
  • Before invasive procedures with significant coagulopathy
  • Not recommended based solely on laboratory values without clinical bleeding 1, 2

Fibrinogen Replacement

• Use cryoprecipitate or fibrinogen concentrate when fibrinogen <1 g/L despite FFP
• Particularly important in severe hypofibrinogenemia that persists despite FFP 1, 2

Factor Concentrates

• Consider prothrombin complex concentrate when FFP is contraindicated due to fluid overload
• Note: These products only partially correct coagulation defects as they contain selected factors, whereas DIC involves global factor deficiency 2

Anticoagulation in DIC

• For DIC where thrombosis predominates (arterial/venous thromboembolism, purpura fulminans):

  • Consider therapeutic doses of unfractionated heparin
  • Weight-adjusted dosing (e.g., 10 μ/kg/h) without necessarily targeting APTT ratio of 1.5-2.5
  • Continuous infusion preferred due to short half-life and reversibility 2

• For critically ill, non-bleeding DIC patients:

  • Prophylactic doses of heparin or LMWH recommended for VTE prevention 1, 2

Special Considerations

• The cornerstone of DIC management is treating the underlying condition 1, 2, 3
• Avoid antifibrinolytic agents in general DIC cases; consider only in primary hyperfibrinolytic states with severe bleeding (e.g., tranexamic acid 1g every 8 hours) 2
• Consider recombinant human activated protein C in severe sepsis with DIC (24 μg/kg/h for 4 days), but avoid in patients with high bleeding risk or platelet counts <30 × 10^9/L 2

Common Pitfalls

• 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, 2
• Delaying treatment of the underlying disease 1
• Misinterpreting normal coagulation screens (normal PT/aPTT does not exclude DIC) 1
• Failing to repeat tests to monitor the dynamic changes in coagulation parameters 1, 2

Remember that DIC management should be tailored according to the clinical presentation (bleeding vs. thrombotic) and laboratory parameters, with the primary focus on treating the underlying condition while providing appropriate supportive care with blood products.