Primary Treatment Approach for Disseminated Intravascular Coagulation (DIC)
The cornerstone of DIC management is aggressive treatment of the underlying disorder (sepsis, malignancy, trauma, obstetric complications), with simultaneous supportive hemostatic therapy guided by bleeding status and specific laboratory thresholds rather than laboratory abnormalities alone. 1, 2, 3
Treatment Algorithm
Step 1: Identify and Treat the Underlying Cause
- This is the fundamental intervention that determines patient survival. 1, 2, 4
- Common triggers requiring immediate attention include: 3, 5
- Sepsis (most common) - requires source control and appropriate antibiotics
- Malignancy - initiate cancer-directed therapy
- Trauma - surgical intervention as needed
- Obstetric complications - delivery or management of eclampsia
- In cancer-associated DIC, early initiation of chemotherapy (particularly in acute promyelocytic leukemia) achieves good resolution of the coagulopathy 1
Step 2: Classify the DIC Phenotype
DIC presents in three distinct forms that guide management: 6
- Procoagulant DIC - thrombosis predominates (requires anticoagulation consideration)
- Hyperfibrinolytic DIC - bleeding predominates (heparin contraindicated)
- Subclinical DIC - laboratory abnormalities without overt clinical manifestations
Step 3: Supportive Hemostatic Management
For Patients WITH Active Bleeding:
- Maintain platelets >50×10⁹/L 1, 2, 4
- Administer fresh frozen plasma (FFP) 15-30 mL/kg for prolonged PT/aPTT 1, 2, 4
- Replace fibrinogen if <1.5 g/L persists despite FFP using cryoprecipitate (2 units) or fibrinogen concentrate 1, 2, 4
For Patients WITHOUT Active Bleeding:
- Do NOT transfuse prophylactically based on laboratory values alone 1, 2, 4
- Consider platelet transfusion only if high bleeding risk AND platelets <20-30×10⁹/L (use <30×10⁹/L for acute promyelocytic leukemia, <20×10⁹/L for other cancers) 1, 4
Step 4: Anticoagulation Decision-Making
Heparin is indicated primarily for thrombotic-predominant DIC, NOT for bleeding-predominant or hyperfibrinolytic DIC. 1, 2, 7
Indications for Therapeutic Anticoagulation:
- Arterial or venous thromboembolism 4
- Severe purpura fulminans with acral ischemia 4
- Vascular skin infarction 4
- Cancer-associated DIC with thrombotic events 1
Contraindications to Heparin:
Heparin Selection:
- Prefer unfractionated heparin (UFH) in patients with high bleeding risk or renal failure due to reversibility and short half-life 1, 4
- Prefer low molecular weight heparin (LMWH) in other cases 1
- For cancer-associated thromboembolism: LMWH at therapeutic dose for 6 months (full dose first month, then 75% dose for 5 months) is superior to warfarin 1
- UFH dosing: FDA-approved for DIC at 10,000 units IV bolus, followed by continuous infusion 7
Prophylactic Anticoagulation:
- In critically ill non-bleeding DIC patients: use prophylactic-dose heparin or LMWH for VTE prevention 4
- In cancer-associated DIC with solid tumors: consider prophylaxis if platelets >20×10⁹/L and no active bleeding 1
Step 5: Monitoring Strategy
- Monitor CBC, PT/aPTT, fibrinogen, and D-dimer daily in acute DIC 2
- A 30% drop in platelet count may indicate subclinical DIC progression even if absolute count remains normal 2
- Adjust monitoring frequency from daily to monthly based on clinical stability 1
Critical Pitfalls to Avoid
- Do not withhold anticoagulation based solely on abnormal coagulation tests in the absence of bleeding - laboratory abnormalities alone are not absolute contraindications 1
- Recognize that normal platelet counts do not exclude DIC in patients with baseline thrombocytosis from malignancy - look for decreasing trends 2
- PT/aPTT may be normal in early or cancer-associated DIC - do not rely solely on these tests 2
- Transfused platelets have very short half-life in DIC with vigorous coagulation activation - repeated transfusions may be necessary 1
- Never use antifibrinolytic agents (tranexamic acid) in general DIC - reserve only for rare primary hyperfibrinolytic DIC with severe bleeding 4