What is the recommended management of disseminated intravascular coagulation, including platelet and plasma transfusion thresholds, fibrinogen replacement, and anticoagulation use?

Management of Disseminated Intravascular Coagulation

The cornerstone of DIC management is aggressive treatment of the underlying disorder (sepsis, malignancy, trauma, obstetric complications), with supportive hemostatic therapy guided by bleeding status and specific laboratory thresholds rather than laboratory abnormalities alone. 1

Immediate Priority: Treat the Underlying Cause

• Identify and aggressively treat the trigger: sepsis requires source control and antibiotics; malignancy requires chemotherapy (particularly effective in acute promyelocytic leukemia); trauma requires surgical intervention; obstetric complications require delivery or management of eclampsia 1
• Early initiation of cancer-directed therapy achieves good resolution of DIC, especially in APL where prompt induction therapy resolves the coagulopathy 2, 1
• Treatment of the underlying condition is more important than any supportive measure, as DIC is always secondary to another process 2, 3

Classify the DIC Phenotype to Guide Management

DIC presents in three distinct forms that require different approaches: 1

• Procoagulant/thrombotic-predominant DIC: associated with solid tumors, requires anticoagulation consideration
• Hyperfibrinolytic DIC: avoid heparin and antifibrinolytics unless therapy-resistant bleeding 2, 1
• Subclinical DIC: laboratory abnormalities without clinical bleeding, benefits from prophylactic anticoagulation 2, 1

Platelet Transfusion Thresholds

Active bleeding: Transfuse platelets to maintain count >50 × 10⁹/L 2, 1, 3

High bleeding risk (surgery, invasive procedures):

• Transfuse 1-2 doses of platelets if count <30 × 10⁹/L in APL 2
• Transfuse if count <20 × 10⁹/L in other cancers 2

Non-bleeding patients: Do not transfuse prophylactically based on laboratory values alone unless perceived high bleeding risk 3

Critical caveat: Transfused platelets have very short lifespan in DIC with vigorous coagulation activation, often requiring repeated transfusions 2, 1

Fresh Frozen Plasma Transfusion

Active bleeding with prolonged PT/aPTT: Administer 15-30 mL/kg with careful clinical monitoring for dose adjustments 2, 1, 3

Volume overload concerns: Use prothrombin complex concentrates instead of FFP, recognizing these only partially correct the defect as they contain selected factors rather than the global deficiency present in DIC 2, 3

Important principle: Do not transfuse FFP based on laboratory abnormalities alone; reserve for active bleeding or immediately pre-procedure 3

Fibrinogen Replacement

Threshold for replacement: If fibrinogen remains <1.5 g/L despite FFP administration in actively bleeding patients 2, 1, 3

Replacement options:

• Two pools of cryoprecipitate (preferred when available) 2
• Fibrinogen concentrate (alternative option) 2

Monitoring note: Fibrinogen depletes first in massive transfusion scenarios, reaching critical levels after approximately 150% blood volume loss 4

Anticoagulation Decision Algorithm

DO use therapeutic anticoagulation for:

• Arterial or venous thromboembolism 3
• Severe purpura fulminans with acral ischemia 3
• Vascular skin infarction 3
• Cancer-associated DIC with thrombotic events (solid tumors) 2, 1

DO use prophylactic anticoagulation for:

• Critically ill non-bleeding patients with DIC 3
• Subclinical DIC without contraindications 2
• Prothrombotic forms of DIC associated with solid cancers 2

DO NOT use anticoagulation for:

• Active bleeding 2, 1
• Platelet count <20 × 10⁹/L 2
• Hyperfibrinolytic DIC 2, 1
• Bleeding-predominant DIC 1

Heparin selection:

• Unfractionated heparin: Use in high bleeding risk with renal failure due to easier reversibility and shorter half-life; consider continuous infusion at weight-adjusted doses (10 units/kg/h) without targeting specific aPTT prolongation 2, 1, 3
• Low molecular weight heparin: Use in all other cases; for solid tumor thromboembolism, administer therapeutic dose for 6 months (full dose month 1, then 75% dose for 5 months) 2
• Monitor anti-Xa levels in hematologic malignancies like APL due to high bleeding risk 2

Critical principle: Abnormal PT/aPTT alone should not contraindicate anticoagulation in thrombotic DIC without bleeding, as there is rebalanced hemostasis with concurrent reduction in natural anticoagulants 2

Monitoring Strategy

Acute DIC: Monitor CBC, PT/aPTT, fibrinogen, and D-dimer daily 1

Stable/subclinical DIC: Adjust monitoring frequency from daily to monthly based on clinical stability 2, 1

Key warning sign: A ≥30% drop in platelet count indicates subclinical DIC progression, even if absolute count remains normal 2, 1, 4

Laboratory markers of progression:

• PT/aPTT prolongation >1.5× normal correlates with increased bleeding risk 4
• Fibrinogen <1.0 g/L with elevated D-dimers confirms consumption beyond dilution 4

Agents to Avoid

Tranexamic acid: Do NOT use routinely in DIC; reserve only for therapy-resistant bleeding in confirmed hyperfibrinolytic DIC, as it increases thrombotic events 1, 3

Recombinant factor VIIa: Discouraged in DIC due to uncertain benefit and definite thrombosis risk 1

Antithrombin concentrate: Cannot be recommended without further prospective evidence demonstrating benefit on clinically relevant endpoints 3

Special Considerations

Cancer-associated DIC: Requires frequent blood monitoring to determine replacement thresholds, as underlying malignancy and organ impairment affect platelet and fibrinogen production 2

Metastatic disease with poor prognosis: Tailor interventions based on physician discretion, patient preferences, and available resources 2

Liver failure: Standard coagulation tests (INR) correlate poorly with bleeding risk; treatment focuses on underlying ACLF triggers with judicious blood product use only for active bleeding 5