From the Guidelines
Immediately treat the underlying cause of DIC while providing supportive care, and transfuse blood products based on laboratory results, such as platelets for counts below 50,000/μL, as suggested by the guidance statement 1. The management of DIC should focus on treating the underlying condition, which could be sepsis, trauma, malignancy, or obstetric complications, as this is crucial for the resolution of the coagulopathy. Some key points to consider in the management of DIC include:
- Transfusing platelets to maintain a count above 50,000/μL in patients with active bleeding, as recommended by 1
- Using fresh frozen plasma (15–30 mL kg-1) with careful clinical monitoring, and considering prothrombin complex concentrates in cases of concerns over volume overload, as suggested by 1
- Transfusing cryoprecipitate or fibrinogen concentrate in actively bleeding cases with persistently low fibrinogen values, as recommended by 1
- Avoiding heparin unless thrombosis predominates or in specific conditions like acute promyelocytic leukemia, and considering therapeutic heparin in thrombosis-predominant DIC, as mentioned in the example answer It is essential to monitor coagulation parameters frequently to guide therapy and adjust the treatment plan accordingly. Additionally, the guidance statement from 1 recommends appropriate treatment of the underlying cancer as the first-line strategy for cancer-related DIC, and prophylactic anticoagulation in all patients with cancer-related DIC, except hyperfibrinolytic DIC, in the absence of contraindications. However, the most recent and highest quality study 1 provides more specific guidance on the management of DIC, which should be prioritized in clinical practice.
From the FDA Drug Label
HEPARIN SODIUM injection, for intravenous or subcutaneous use ... Heparin sodium injection is an anticoagulant indicated for ... Treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation) ... Recommended Adult Dosages: Therapeutic Anticoagulant Effect with Full-Dose Heparin† ( 2. 3) ... Initial Dose10,000 units, either undiluted or in 50 to 100 mL of 0.9% Sodium Chloride Injection, USP ... Continuous 20,000 to 40,000 units/24 hours in 1,000 mL of 0. 9% Sodium Chloride Injection, USP (or in any compatible solution) for infusion
For a patient going into Disseminated Intravascular Coagulation (DIC), Heparin Sodium Injection can be used as an anticoagulant. The recommended initial dose is 10,000 units either undiluted or in 50 to 100 mL of 0.9% Sodium Chloride Injection, USP. Alternatively, a continuous infusion of 20,000 to 40,000 units/24 hours in 1,000 mL of 0.9% Sodium Chloride Injection, USP can be used 2.
- Key considerations:
- Monitor for signs and symptoms of hemorrhage, HIT, and HITTS.
- Periodically monitor platelet count, hematocrit, and occult blood in stool.
- Measure blood potassium in patients at risk of hyperkalemia before starting heparin therapy and periodically in all patients.
- Important warnings:
- Fatal medication errors can occur, confirm the choice of correct strength prior to administration.
- Hemorrhage, including fatal events, has occurred in patients receiving heparin.
From the Research
Diagnosis and Treatment of Disseminated Intravascular Coagulation (DIC)
- The diagnosis of DIC should encompass both clinical and laboratory information, utilizing the International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system for objective measurement 3.
- Treatment of the underlying condition is the cornerstone of DIC management, with supportive care including transfusion of platelets or plasma components in patients with bleeding 3, 4.
- Platelet transfusion should be considered in patients with DIC and bleeding or at high risk of bleeding, with a platelet count of <50 x 10(9)/l 3, 5.
- In non-bleeding patients with DIC, prophylactic platelet transfusion is not recommended unless there is a high risk of bleeding 3.
- Administration of fresh frozen plasma (FFP) may be useful in bleeding patients with DIC and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) 3, 4.
Management of Bleeding and Thrombosis in DIC
- In patients with DIC and severe bleeding, treatment with recombinant human activated protein C may be considered, but not in patients at high risk of bleeding 3.
- Thromboprophylaxis with low-molecular-weight heparin is advised until bleeding ensues or platelet count drops below 30×10⁹/l 5.
- In cases of DIC where thrombosis predominates, therapeutic doses of heparin should be considered, with careful monitoring for signs of bleeding 3.
- Severe hypofibrinogenaemia (<1 g/l) that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate 3.
Monitoring and Supportive Care
- Close and repeated clinical and laboratory monitoring is essential in the management of DIC, with treatment adjusted according to the underlying cause, clinical manifestations, and severity of blood test abnormalities 4, 5.
- Nurses play a key role in early recognition of DIC, with prompt treatment crucial to reducing fatality 6.
- Supportive management strategies should be individualized based on the type of underlying disease, presence of bleeding or thrombotic complications, and laboratory test results 5.