From the Guidelines
The primary treatment approach for disseminated intravascular coagulation (DIC) should focus on addressing the underlying cause and providing supportive care to manage coagulation abnormalities, with the use of platelet transfusion to maintain the platelet count above 50 × 10^9/L in patients with active bleeding, as suggested by the guidance from the SSC of the ISTH 1.
Key Considerations
- The management of DIC involves identifying and treating the triggering condition, which may include sepsis, trauma, malignancy, or obstetric complications.
- Supportive measures include blood component therapy with:
- Platelets, typically given when counts fall below 50 × 10^9/L, especially in patients with active bleeding or at high risk of bleeding 1.
- Fresh frozen plasma (15–30 mL/kg) with careful clinical monitoring to decide on dose adjustments, and considering the use of prothrombin complex concentrates in cases of concerns over volume overload 1.
- Cryoprecipitate or fibrinogen concentrate in actively bleeding cases with persistently low fibrinogen values (below 1.5 g/L) despite supportive measures 1.
- Heparin therapy, either unfractionated or low-molecular-weight, may be beneficial in cases with predominant thrombosis, particularly in purpura fulminans or acral ischemia, but its use should be considered cautiously due to the risk of bleeding, especially in patients with low platelet count or active bleeding 1.
Monitoring and Adjustments
- Continuous monitoring of coagulation parameters (platelet count, fibrinogen, PT/INR, aPTT, D-dimer) is essential to guide therapy and adjust supportive measures as needed.
- The choice of heparin, whether unfractionated or low-molecular-weight, should be based on the patient's risk of bleeding and renal function, with unfractionated heparin preferred in cases of high bleeding risk and renal failure due to its easier reversibility 1.
From the Research
Treatment of Disseminated Intravascular Coagulation
The treatment of disseminated intravascular coagulation (DIC) is aimed at combating the underlying disorder followed by supportive management 2. The cornerstone of the treatment of DIC is treatment of the underlying condition 3, 4, 5.
Supportive Management
Supportive management includes:
- Transfusion of platelets or plasma (components) in patients with DIC should not primarily be based on laboratory results and should in general be reserved for patients who present with bleeding 5.
- In patients with DIC and bleeding or at high risk of bleeding, transfusion of platelets should be considered if the platelet count is <50 x 10(9)/l 5.
- In bleeding patients with DIC and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), administration of fresh frozen plasma (FFP) may be useful 5.
- Severe hypofibrinogenaemia (<1 g/l) that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate 5.
Anticoagulation Therapy
Anticoagulation therapy may be considered in certain situations:
- In cases of DIC where thrombosis predominates, therapeutic doses of heparin should be considered 5.
- In critically ill, non-bleeding patients with DIC, prophylaxis for venous thromboembolism with prophylactic doses of heparin or low molecular weight heparin is recommended 5.
- Targeting anticoagulation therapy with antithrombin concentrates and recombinant thrombomodulin for the prevention of microthrombus formation may be considered 6, 3.
Other Therapies
Other therapies that may be considered include:
- Activated protein C, which may be beneficial in patients with severe sepsis and DIC, but should not be given to patients at high risk of bleeding 5.
- Antifibrinolytic agents, such as tranexamic acid, which may be considered in patients with DIC characterized by a primary hyperfibrinolytic state and severe bleeding 5.