What is the primary approach to managing Disseminated Intravascular Coagulation (DIC)?

Management of Disseminated Intravascular Coagulation (DIC)

The primary approach to managing DIC is to treat the underlying cause while providing supportive care with blood products based on clinical bleeding status rather than laboratory results alone. 1, 2

Understanding DIC Classification

DIC can be categorized into three subtypes based on clinical presentation 3:

1. Procoagulant DIC: Characterized by thrombosis, common in pancreatic cancer and adenocarcinomas
2. Hyperfibrinolytic DIC: Characterized by bleeding, common in acute promyelocytic leukemia and metastatic prostate cancer
3. Subclinical DIC: Only laboratory abnormalities without obvious clinical symptoms

Diagnostic Approach

The International Society on Thrombosis and Haemostasis (ISTH) scoring system provides an objective measurement for diagnosing DIC 1, 2:

Parameter	Score	Range
Platelet count (×10⁹/L)	2	<50
	1	≥50, <100
Fibrin-related markers (D-dimer/FDP)	3	Strong increase
	2	Moderate increase
Prothrombin time (PT)	2	≥6 seconds prolongation (PT ratio >1.4)
	1	≥3 seconds, <6 seconds prolongation (PT ratio >1.2, ≤1.4)
Fibrinogen (g/L)	1	<1.0

• A score ≥5 points confirms overt DIC
• Serial monitoring is essential as DIC is a dynamic process 2

Management Algorithm

Step 1: Treat the Underlying Cause

• This is the cornerstone of DIC management 1, 2, 4
• Examples include antibiotics for sepsis, chemotherapy for malignancy, delivery for obstetric complications

Step 2: Provide Blood Product Support Based on Clinical Status

For Patients with Active Bleeding:

1. Platelet Transfusion:

   • Maintain platelet count >50 × 10⁹/L 1, 2
   • Target higher counts (>100 × 10⁹/L) for CNS injury or multiple trauma 1

2. Fresh Frozen Plasma (FFP):

   • Administer 15-30 mL/kg with careful clinical monitoring 1
   • Consider prothrombin complex concentrates if volume overload is a concern 1, 2

3. Fibrinogen Replacement:

   • If fibrinogen remains <1.5 g/L despite other measures, administer cryoprecipitate or fibrinogen concentrate 1, 2

For Non-Bleeding Patients:

1. Platelet Transfusion:

   • Generally not recommended prophylactically 2
   • Consider if platelet count <20-30 × 10⁹/L in high-risk patients 1

2. Thromboprophylaxis:

   • Use prophylactic doses of heparin or low molecular weight heparin in critically ill, non-bleeding patients 2
   • Continue until bleeding ensues or platelet count drops below 30×10⁹/L 4

Step 3: Consider Special Situations

For DIC with Predominant Thrombosis:

• Consider therapeutic doses of heparin, especially for:
  • Arterial or venous thromboembolism
  • Severe purpura fulminans with acral ischemia
  • Vascular skin infarction 2
• Continuous infusion unfractionated heparin (10 μ/kg/h) may be preferred due to its short half-life and reversibility 2

For Hyperfibrinolytic DIC:

• Antifibrinolytic agents (e.g., tranexamic acid 1g every 8h) may be considered only in cases of primary hyperfibrinolysis with severe bleeding 2
• Generally, antifibrinolytic agents should be avoided in most DIC cases 2

Common Pitfalls to Avoid

1. Overlooking the short lifespan of transfused products in active DIC 1
2. Using antifibrinolytic agents without clear indication of hyperfibrinolytic DIC 1, 2
3. Delaying treatment of the underlying disease 1
4. Misinterpreting normal coagulation screens - a normal PT/aPTT does not exclude DIC, especially in subclinical forms 1
5. Attempting to correct laboratory values without clinical correlation - transfusion should not be based solely on laboratory results 2
6. Using recombinant Factor VIIa without evidence in DIC 1

Special Considerations

• In liver disease, bleeding is primarily related to portal hypertension rather than coagulopathy 1
• Do not routinely correct prolonged PT before procedures in patients with cirrhosis, as it does not predict bleeding risk 1
• For severe sepsis with DIC, recombinant human activated protein C was previously recommended but has been withdrawn from the market due to bleeding risks 5

The management of DIC requires a dynamic approach with frequent reassessment of clinical status and laboratory parameters to guide ongoing treatment decisions.