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

Management of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is aggressive treatment of the underlying condition (sepsis, malignancy, trauma, obstetric complications), combined with supportive care using blood product transfusions based on specific clinical thresholds and, in selected cases, anticoagulation with heparin. 1, 2, 3

Immediate Priorities

Treat the Underlying Cause First

• Identify and aggressively manage the precipitating condition—this is the single most important intervention that will determine survival 4, 1, 3
• In cancer-related DIC, initiate definitive cancer therapy immediately (chemotherapy, surgery, radiation as appropriate) 4
• In sepsis-related DIC, provide source control and appropriate antimicrobials 5
• In acute promyelocytic leukemia, early initiation of all-trans retinoic acid achieves excellent DIC resolution 2

Establish Monitoring Protocol

• Check complete blood count, PT/INR, aPTT, fibrinogen, and D-dimer at baseline 1, 2
• In acute DIC with active bleeding: repeat coagulation studies every 4-6 hours initially 6, 7
• In stable chronic DIC: monitor daily to weekly depending on clinical status 2
• Monitor for organ dysfunction (renal, hepatic, respiratory) as microvascular thrombosis progresses 1, 3

Blood Product Transfusion Strategy

Platelet Transfusion Thresholds

• Active bleeding: Maintain platelets >50×10⁹/L 2, 7
• High bleeding risk without active hemorrhage (e.g., pre-procedure): Transfuse if <50×10⁹/L 7
• Acute promyelocytic leukemia without bleeding: Transfuse if <30×10⁹/L 2
• Other cancers without bleeding: Transfuse if <20×10⁹/L 2
• Prophylactic transfusion in non-bleeding patients: Generally not recommended unless high bleeding risk 7

Critical caveat: Platelet half-life may be extremely short (hours) in DIC with vigorous coagulation activation, requiring frequent reassessment 2

Fresh Frozen Plasma (FFP)

• Active bleeding with prolonged PT/aPTT: Administer 15-30 mL/kg 2, 7
• Do NOT transfuse based solely on laboratory abnormalities in non-bleeding patients 7
• There is no evidence that FFP infusion worsens ongoing coagulation activation 7

Fibrinogen Replacement

• Active bleeding with fibrinogen persistently <1.5 g/L despite FFP: Give 2 units cryoprecipitate or fibrinogen concentrate 2, 7
• Severe hypofibrinogenemia (<1 g/L) warrants replacement even without active bleeding 7

Anticoagulation Strategy

When to Use Heparin

The decision to anticoagulate depends on whether thrombosis or bleeding predominates:

Therapeutic-dose heparin is indicated for: 4, 6, 7

• Arterial or venous thromboembolism in DIC patients
• Severe purpura fulminans with acral ischemia
• Vascular skin infarction
• Cancer-related DIC with thrombotic predominance

Prophylactic-dose heparin is recommended for: 4, 7

• All cancer-related DIC patients (except hyperfibrinolytic DIC) without contraindications
• Critically ill non-bleeding DIC patients for VTE prophylaxis
• Contraindications: platelets <20×10⁹/L or active bleeding 2

Heparin Dosing and Monitoring

• Therapeutic anticoagulation: Use "therapeutic" doses adequate to overcome the coagulant forces—standard weight-based dosing may be insufficient in DIC's heparin-resistant state 8
• Unfractionated heparin (UFH): Preferred in high bleeding risk or renal failure due to short half-life and reversibility 2, 7
  • Consider continuous infusion at 10 units/kg/hour without necessarily targeting aPTT 1.5-2.5× control in thrombotic DIC with bleeding risk 7
• Low molecular weight heparin (LMWH): Preferred in other cases for ease of administration 2
• Solid tumor with thromboembolism: LMWH at therapeutic dose for 1 month, then 75% dose for 5 months (superior to warfarin) 2

Critical warning: Do NOT use heparin in hyperfibrinolytic DIC or in patients with active bleeding 4, 2

Special Considerations

Hyperfibrinolytic DIC

• Avoid routine tranexamic acid—it increases thrombotic risk and is strongly discouraged 4, 1
• Consider tranexamic acid ONLY if: 4, 1
  • Therapy-resistant bleeding dominates the clinical picture
  • Hyperfibrinolysis confirmed by APTEM testing (thromboelastometry)
  • Dosing: 10-15 mg/kg loading dose, then 1-5 mg/kg/hour infusion 1
• Never use tranexamic acid in non-hyperfibrinolytic DIC—it may be deleterious 4, 1

Recombinant Factor VIIa

• Not recommended—no randomized controlled trial evidence and definite thrombotic risks 4

Severe Thrombocytopenia with New Thrombosis

When platelets are <25-50×10⁹/L and new thrombosis develops, three approaches exist (no clear consensus): 4

1. Platelet transfusions plus therapeutic anticoagulation
2. Intermediate or prophylactic-dose anticoagulation without transfusions
3. No anticoagulation unless thrombus location is critical (e.g., pulmonary embolism vs. calf DVT)

IVC Filter Placement

• Temporary filter only if proximal lower limb thrombosis likely to embolize AND patient cannot be anticoagulated 4
• Generally avoid—filters can further activate coagulation 4

Coagulation Abnormalities Are NOT Absolute Contraindications

• Laboratory abnormalities alone should not prevent anticoagulation in the absence of active bleeding 2
• Clinical judgment regarding bleeding risk supersedes laboratory values 7

Common Pitfalls to Avoid

• Do not transfuse prophylactically based on laboratory values alone—reserve for active bleeding or high-risk situations 7
• Do not use warfarin for chronic DIC—it is ineffective; use subcutaneous heparin instead 8
• Do not delay treatment of underlying condition while focusing solely on coagulation parameters 1, 3
• Do not use antifibrinolytics routinely—they worsen outcomes except in confirmed hyperfibrinolytic DIC with refractory bleeding 4, 1, 7
• Confirm correct heparin vial strength before administration to prevent fatal medication errors 6