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

Management of Disseminated Intravascular Coagulation (DIC)

Treat the underlying disease process immediately—this is the absolute cornerstone of DIC management and takes priority over all supportive measures. 1, 2

Primary Treatment Algorithm

Step 1: Address the Root Cause (Non-Negotiable Priority)

The fundamental approach is identifying and aggressively treating the underlying condition driving the coagulopathy 1, 2, 3:

• In sepsis-associated DIC: Implement source control and appropriate antibiotics immediately 1
• In cancer-associated DIC: Initiate definitive cancer therapy (chemotherapy, surgery, or radiation) without delay 1, 2
• In acute promyelocytic leukemia: Start all-trans retinoic acid early, which achieves excellent DIC resolution 1, 2
• In obstetrical complications or trauma: Address the specific obstetrical or traumatic trigger 4

Without treating the underlying cause, all supportive measures are temporizing at best and futile at worst 2, 3.

Step 2: Classify the DIC Subtype (Determines Management Strategy)

The ISTH recognizes three distinct forms requiring different approaches 1:

Procoagulant DIC (thrombosis predominates):

• Common in pancreatic cancer and adenocarcinomas 1
• Presents with arterial ischemia, venous thromboembolism, or microvascular thrombosis 1
• Requires prophylactic or therapeutic anticoagulation 1, 2

Hyperfibrinolytic DIC (bleeding predominates):

• Typical of acute promyelocytic leukemia and metastatic prostate cancer 1
• Presents with widespread bleeding from multiple sites 1
• Avoid heparin in this subtype 1, 2

Subclinical DIC:

• Diagnosed by ≥30% drop in platelet count even when absolute values remain normal 1, 2
• Requires close monitoring and early intervention 1

Step 3: Provide Supportive Hemostatic Measures (Only for Active Bleeding or High-Risk Procedures)

Do not transfuse based solely on laboratory abnormalities 5, 3. Transfuse only for active bleeding or immediately before invasive procedures 3:

Platelet transfusion thresholds:

• Active bleeding: Maintain >50×10⁹/L 1, 2, 5
• High bleeding risk without active hemorrhage: Transfuse if <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 2
• Critical caveat: Transfused platelet half-life is extremely short in DIC with vigorous coagulation activation 2, 5

Fresh frozen plasma (FFP):

• Administer 15-30 mL/kg for prolonged coagulation times with active bleeding 1, 2, 5
• Do not give FFP based on laboratory values alone—there is no evidence that plasma infusion stimulates ongoing coagulation activation 3

Fibrinogen replacement:

• If fibrinogen remains <1.5 g/L despite FFP, give 2 units of cryoprecipitate or fibrinogen concentrate 1, 2, 5

Step 4: Implement Anticoagulation Strategy (Subtype-Dependent)

Initiate prophylactic anticoagulation with heparin in all patients EXCEPT those with hyperfibrinolytic DIC, unless contraindications exist 1, 2:

First-line anticoagulation:

• Use low molecular weight heparin (LMWH) as first choice for most patients 1, 2
• In patients with high bleeding risk and renal failure, prefer unfractionated heparin for its reversibility 2

Escalation criteria:

• Escalate to therapeutic-dose anticoagulation if arterial or venous thrombosis develops 1
• In severe purpura fulminans with acral ischemia or vascular skin infarction, use therapeutic heparin doses 3

Contraindications to anticoagulation:

• Platelets <20×10⁹/L 2
• Active bleeding 2
• However, coagulation test abnormalities alone are NOT an absolute contraindication in the absence of bleeding 2

Special consideration for solid tumor-associated thromboembolism:

• Use LMWH at therapeutic dose for 6 months (full dose for first month, then 75% dose for 5 months)—this is superior to warfarin 2

Step 5: Monitor Dynamically

Repeat laboratory testing regularly to track the evolving clinical picture 1, 2, 3:

• Monitor complete blood count, PT, aPTT, fibrinogen, and D-dimer 1, 2
• Frequency ranges from daily in acute severe DIC to monthly in chronic stable DIC 1, 2
• Sequential screening on ICU admission and 2 days later is associated with lower mortality 1

Critical Pitfalls to Avoid

• Never use antifibrinolytic agents (tranexamic acid) routinely—they may increase thrombotic events and are contraindicated except in rare hyperfibrinolytic scenarios 5, 3
• Do not use recombinant FVIIa routinely—thrombotic risks outweigh benefits without controlled trial evidence 5
• Avoid prophylactic transfusions based solely on laboratory values in non-bleeding patients without high bleeding risk 5, 3
• Do not delay treatment of the underlying condition while focusing on laboratory abnormalities 1, 2, 3
• Recognize that coagulation test abnormalities alone should not prevent necessary anticoagulation in thrombotic DIC 2

Special Clinical Scenarios

For proximal lower limb thrombosis when anticoagulation is contraindicated:

• Consider temporary IVC filter placement 1

In sepsis with coagulopathy:

• Use the ISTH SIC score (≥4 points) followed by overt DIC score (≥5 points) for sequential screening 1
• Anticoagulant therapy may improve outcomes specifically in septic patients with coagulopathy, though evidence remains controversial 1