What is the management of Disseminated Intravascular Coagulation (DIC) in the Intensive Care Unit (ICU)?

Management of Disseminated Intravascular Coagulation (DIC) in the ICU

Treat the underlying disease process immediately—this is the cornerstone of DIC management and takes absolute priority over all other interventions. 1

Diagnostic Approach

Use a two-step sequential screening approach to identify patients who will benefit from specific therapies:

• First, screen for Sepsis-Induced Coagulopathy (SIC) using the ISTH SIC score (≥4 points indicates SIC), which identifies earlier-phase coagulopathy more amenable to intervention 2
• Second, apply the ISTH overt DIC score (≥5 points indicates overt DIC) for patients with more advanced coagulopathy 2
• Screen on ICU admission day and repeat 2 days later, as this sequential screening is associated with lower mortality 2
• Monitor complete blood count and coagulation parameters (PT, fibrinogen, D-dimer) daily in acute severe DIC 1
• A 30% or greater drop in platelet count is diagnostic of subclinical DIC, even when absolute values remain normal 1

Key scoring components:

• Platelet count, PT ratio, fibrinogen, D-dimer/FDP, and SOFA score (for SIC) 2

Treatment Algorithm by DIC Subtype

DIC manifests in three distinct forms requiring different management strategies: 1

Procoagulant DIC (Thrombosis Predominates)

• Common in pancreatic cancer and adenocarcinomas 1
• Initiate prophylactic anticoagulation with low molecular weight heparin (LMWH) as first choice unless contraindications exist (platelets <20×10⁹/L or active bleeding) 1, 3
• Escalate to therapeutic-dose anticoagulation if arterial or venous thrombosis develops 1
• For severe purpura fulminans with acral ischemia or vascular skin infarction, use therapeutic doses of unfractionated heparin (UFH) at weight-adjusted doses (10 units/kg/h) without necessarily targeting APTT prolongation 3
• Consider temporary IVC filter placement if proximal lower limb thrombosis is present but anticoagulation is contraindicated 1

Hyperfibrinolytic DIC (Bleeding Predominates)

• Typical of acute promyelocytic leukemia and metastatic prostate cancer 1
• Avoid heparin in this subtype 1
• Focus on aggressive replacement therapy and treating underlying malignancy 1
• For acute promyelocytic leukemia specifically, initiate all-trans retinoic acid immediately for good DIC resolution 1

Sepsis-Associated DIC

• Source control and appropriate antibiotics are essential 1
• Initiate prophylactic anticoagulation with heparin in all patients except those with hyperfibrinolytic DIC, unless contraindications exist 1
• In critically ill, non-bleeding patients with DIC, use prophylactic doses of heparin or LMWH for venous thromboembolism prevention 3

Supportive Hemostatic Measures

Transfusion thresholds should guide replacement therapy, not laboratory values alone:

Platelet Transfusion

• Maintain platelet count >50×10⁹/L in patients with active bleeding 1, 3
• In high-risk bleeding without active hemorrhage: transfuse if platelets <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 1
• In non-bleeding patients, prophylactic platelet transfusion is not recommended unless high bleeding risk is perceived 3
• Important caveat: Platelet half-life may be very short in DIC with vigorous coagulation activation 1

Fresh Frozen Plasma (FFP)

• Administer 15-30 mL/kg of FFP in bleeding patients with prolonged PT/aPTT 1, 3
• Do not transfuse based on laboratory tests alone—reserve for active bleeding or pre-procedure 3
• There is no evidence that plasma infusion stimulates ongoing coagulation activation 3

Fibrinogen Replacement

• Replace fibrinogen with cryoprecipitate (2 units) or fibrinogen concentrate if levels remain <1.5 g/L despite FFP 1, 3
• Severe hypofibrinogenemia (<1 g/L) persisting despite FFP requires specific fibrinogen replacement 3

Factor Concentrates

• If FFP transfusion is impossible due to fluid overload in bleeding patients, consider prothrombin complex concentrate, recognizing this only partially corrects the defect 3

Anticoagulation Strategy Details

The decision to anticoagulate depends on DIC subtype and bleeding risk:

• LMWH is preferred in most patients due to ease of administration and predictable pharmacokinetics 1
• Use UFH in patients with high bleeding risk and renal failure due to its short half-life and reversibility 1
• In patients with perceived high bleeding risk requiring therapeutic anticoagulation, use continuous infusion UFH at weight-adjusted doses without necessarily targeting APTT prolongation of 1.5-2.5 times control 3
• Abnormal coagulation tests alone should not be considered an absolute contraindication to anticoagulation in the absence of active bleeding 1
• Anticoagulant therapy may improve outcomes specifically in septic patients with coagulopathy or DIC, though evidence remains controversial 2

Adjunctive Therapies (Limited Evidence)

These agents have shown potential benefit in subgroup analyses but lack definitive evidence:

• Consider recombinant human activated protein C (24 mcg/kg/h continuous infusion for 4 days) in severe sepsis with DIC, but avoid if platelet count <30×10⁹/L or high bleeding risk 3
• Antithrombin concentrate cannot be recommended based on current evidence from randomized controlled trials 3
• Avoid antifibrinolytic agents (tranexamic acid) in general DIC, except in rare cases of primary hyperfibrinolytic DIC with severe bleeding (tranexamic acid 1 g every 8 hours) 3
• Thrombomodulin and tissue factor pathway inhibitor have shown promising results in clinical studies but require further validation 4

Critical Pitfalls to Avoid

• Do not delay treatment of the underlying disease while focusing on coagulation abnormalities—this is the most common error 1, 5
• Do not transfuse products prophylactically based solely on laboratory values in non-bleeding patients 3
• Do not use heparin in hyperfibrinolytic DIC 1
• Do not assume normal PT and platelet count exclude DIC—chronic DIC may have normal routine tests 6
• Recognize that patients with advanced overt DIC may have illness progression no longer amenable to anticoagulant therapy benefit 2
• Serial monitoring is essential as DIC is a dynamically changing scenario 3