In Disseminated Intravascular Coagulation (DIC), when to use heparin versus Fresh Frozen Plasma (FFP)?

DIC Management: Heparin vs FFP

Use FFP for active bleeding with coagulopathy; use heparin for thrombotic-predominant DIC without active bleeding or severe thrombocytopenia.

Treatment Algorithm

First Priority: Treat the Underlying Cause

• The cornerstone of DIC management is treating the underlying condition (sepsis, malignancy, trauma, obstetric complications) 1, 2
• All other interventions are supportive measures while addressing the primary trigger 3, 4

When to Use FFP

Indications for FFP:

• Active bleeding with prolonged PT/aPTT: administer 15-30 mL/kg 1, 2, 5
• DIC with evidence of bleeding or high bleeding risk (e.g., planned invasive procedure) 1, 3
• Do NOT transfuse FFP prophylactically based solely on abnormal coagulation tests in stable, non-bleeding patients 1, 5

Additional coagulation factor replacement:

• If fibrinogen remains <1.5 g/L despite FFP: give cryoprecipitate (2 pools) or fibrinogen concentrate 1, 2
• Maintain platelets >50×10⁹/L in actively bleeding patients 2, 5, 3

When to Use Heparin

Primary indications for heparin:

• Thrombotic-predominant DIC with arterial/venous thromboembolism, purpura fulminans with acral ischemia, or vascular skin infarction 1, 3, 6
• Prophylactic anticoagulation in cancer-associated DIC (especially solid tumors) without contraindications 1, 2
• Non-bleeding critically ill patients with DIC: prophylactic dose LMWH or UFH for VTE prevention 3, 4

Absolute contraindications to heparin:

• Active bleeding 1, 5
• Platelet count <20×10⁹/L 1, 5
• Hyperfibrinolytic DIC (avoid heparin entirely in this subtype) 1, 2

Choice of heparin formulation:

• UFH preferred in high bleeding risk and renal failure (easier reversibility) 1
• LMWH preferred in all other cases 1
• For therapeutic anticoagulation in solid tumor-associated thrombosis: LMWH for 6 months (full dose month 1, then 75% dose for 5 months) 1

Critical Pitfalls to Avoid

Common errors:

• Never transfuse FFP or platelets prophylactically based on laboratory values alone in stable patients without bleeding 1, 5, 3
• Abnormal PT/aPTT alone should NOT be considered an absolute contraindication to anticoagulation in the absence of bleeding, as there is rebalanced hemostasis with concurrent reduction in natural anticoagulants 1
• Standard coagulation tests (PT, APTT) are poor predictors of bleeding in critically ill patients and do not reflect true hemostatic status 1

Monitoring considerations:

• Transfused platelets and fibrinogen have very short half-life in DIC with vigorous coagulation activation 1, 2
• PTT monitoring of UFH may be problematic as it's already prolonged in DIC; consider anti-FXa activity assays instead 1
• Monitor CBC, PT/aPTT, fibrinogen, and D-dimer regularly (daily in acute DIC) 2, 5

Special Populations

Cancer-associated DIC:

• Heparin prophylaxis recommended in solid tumors unless platelets <20×10⁹/L or active bleeding 1
• In acute promyelocytic leukemia: maintain platelets >30×10⁹/L (higher threshold than other cancers) 1, 2

Hyperfibrinolytic DIC:

• Avoid heparin completely 1, 2
• Consider tranexamic acid only if therapy-resistant bleeding dominates, though routine use is not recommended 1