What is the immediate management of disseminated intravascular coagulation (DIC)?

Immediate Management of Disseminated Intravascular Coagulation (DIC)

The immediate management of DIC requires aggressive treatment of the underlying trigger while simultaneously providing supportive hemostatic therapy guided by the clinical phenotype—bleeding-predominant DIC requires transfusion support, thrombosis-predominant DIC requires anticoagulation, and both require urgent identification and reversal of the precipitating cause. 1

Step 1: Identify and Treat the Underlying Trigger

This is the primary therapeutic goal—DIC will not resolve without addressing the root cause. 1, 2

• Sepsis: Initiate source control and appropriate antibiotics immediately 1
• Malignancy: Begin cancer-directed therapy urgently; in acute promyelocytic leukemia, early chemotherapy produces rapid DIC resolution 3, 1
• Trauma: Perform surgical intervention for hemorrhage control 1
• Obstetric complications: Deliver the fetus, manage eclampsia, inspect for retained tissue, uterine atony, or cervical/vaginal lacerations 4, 1

Step 2: Determine the Clinical Phenotype

DIC presents in three distinct forms that dictate management strategy 1, 2:

Bleeding-Predominant (Hyperfibrinolytic) DIC

• Common in acute promyelocytic leukemia and metastatic prostate cancer 2
• Presents with widespread bruising, mucosal bleeding, CNS hemorrhage, or gastrointestinal bleeding 2
• Management priority: Aggressive transfusion support; avoid heparin 2

Thrombosis-Predominant (Procoagulant) DIC

• Common in pancreatic cancer and other adenocarcinomas 2
• Presents with arterial ischemia (digital ischemia, stroke), venous thromboembolism, or purpura fulminans 2
• Management priority: Therapeutic anticoagulation 1, 2

Subclinical DIC

• Laboratory abnormalities (thrombocytopenia, low fibrinogen, elevated D-dimer) without overt bleeding or thrombosis 2
• A ≥30% drop in platelet count indicates progression even if absolute values remain normal 3, 1

Step 3: Supportive Hemostatic Management for Bleeding-Predominant DIC

Platelet Transfusion

• Active bleeding: Maintain platelets >50 × 10⁹/L 3, 1, 2
• High bleeding risk (surgery/procedures) without active bleeding: Transfuse if platelets <30 × 10⁹/L in acute promyelocytic leukemia or <20 × 10⁹/L in other cancers 3, 2
• Expect rapid consumption; repeated dosing is often necessary 4, 1

Fresh Frozen Plasma (FFP)

• Administer 15–30 mL/kg for prolonged PT/aPTT with active bleeding 3, 4, 1, 2
• Dose adjustments should be guided by clinical response, not isolated laboratory values 2
• If volume overload is a concern, prothrombin complex concentrates may be used, but PCC should generally be avoided in DIC due to increased thrombotic risk 4

Fibrinogen Replacement

• Replace when fibrinogen <1.5 g/L persists despite FFP using two pools of cryoprecipitate or fibrinogen concentrate 4, 1, 2
• In actively bleeding patients, fibrinogen <1.0 g/L is an indication for cryoprecipitate 2

Massive Transfusion Protocol

• For severe hemorrhage, use a 1:1:1 ratio of packed red cells, FFP, and platelets 4

Critical Caveat

• Do not transfuse solely based on laboratory abnormalities in the absence of clinical bleeding or procedural risk 4, 1, 2

Step 4: Anticoagulation for Thrombosis-Predominant DIC

Indications for Therapeutic Anticoagulation

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

Choice of Anticoagulant

• Preferred: Low-molecular-weight heparin 4, 1
• Alternative: Unfractionated heparin when rapid reversibility is needed (ongoing bleeding risk or renal impairment) 4, 1

Prophylactic Anticoagulation

• Initiate once active bleeding is controlled, unless platelets <20 × 10⁹/L 4, 1
• Do not withhold anticoagulation solely because PT/aPTT are prolonged—DIC reflects a rebalanced hemostatic state 1, 2

Contraindications

• Avoid heparin in hyperfibrinolytic DIC—it will worsen bleeding 1, 2

Step 5: Agents to Avoid

• Tranexamic acid: Not routinely recommended; reserve only for refractory bleeding with documented hyperfibrinolysis on thromboelastography 4, 1, 2
• Recombinant factor VIIa: Not recommended due to uncertain benefit and definite thrombotic risk 4, 1, 2
• Prothrombin complex concentrate: Should not be used routinely in DIC due to increased thrombotic risk and unbalanced factor replacement 4
• Corticosteroids and antiplatelet agents: No established benefit; may increase bleeding 4, 2

Step 6: Monitoring Strategy

• Perform serial laboratory assessments: CBC, PT/aPTT, fibrinogen, D-dimer 3, 1, 2
• Frequency: Hourly to every 6 hours in acute severe DIC; daily in stable DIC; adjust to monthly in chronic stable cases 3, 1
• A ≥30% drop in platelet count can indicate worsening DIC even if absolute values remain within normal range 3, 1
• Monitor for organ dysfunction and verify the underlying trigger is being adequately treated 2

Common Pitfalls to Avoid

• Do not delay surgical re-exploration when ongoing bleeding suggests a surgical source 4
• Do not withhold prophylactic anticoagulation after bleeding stops solely because coagulation tests remain abnormal 4, 1
• Do not assume all coagulopathy is DIC—rule out surgical bleeding, dilutional coagulopathy from massive transfusion, and other causes 4
• Do not ignore a "normal" platelet count if it represents a significant drop from a previously elevated baseline—this may be the only sign of DIC in some malignancies 3
• Recognize that PT/aPTT may be normal in subclinical cancer-associated DIC, especially when coagulation factors are only moderately decreased 3