From the Guidelines
Disseminated Intravascular Coagulation (DIC) should be managed with heparin, either unfractionated (UFH) or low-molecular-weight (LMWH), as a prophylactic therapy in the absence of contraindications, to inhibit excess thrombin generation, as recommended by the guidance from the SSC of the ISTH 1.
Overview of DIC
DIC is a serious condition characterized by the abnormal activation of the blood's clotting system throughout the body, leading to both widespread clot formation and severe bleeding. It occurs as a complication of other severe illnesses like sepsis, trauma, malignancy, or obstetric emergencies. Patients typically present with bleeding from multiple sites, including puncture wounds, gums, and surgical sites.
Diagnosis and Treatment
Diagnosis involves laboratory tests showing decreased platelets, prolonged clotting times, elevated D-dimer, and decreased fibrinogen. Treatment focuses on addressing the underlying cause while providing supportive care, which may include blood product transfusions (platelets, fresh frozen plasma, cryoprecipitate) to replace depleted clotting factors.
Use of Heparin in DIC Management
The use of heparin in DIC management is supported by the idea of inhibiting excess thrombin generation, which is a key feature of the condition 1. Heparin can be used in either its unfractionated (UFH) or low-molecular-weight (LMWH) form. The choice between UFH and LMWH depends on the patient's risk of bleeding and renal failure, with UFH preferred in cases of high bleeding risk and renal failure due to its easier reversibility, and LMWH recommended in all other cases 1.
Monitoring and Safety
Monitoring the antithrombotic capacity of UFH using PTT may be problematic in DIC due to the potential for prolonged PTT values. In such cases, the use of heparin anti-FXa activity assays as an alternate method for monitoring can be considered 1. The safety of heparin therapy in DIC, particularly in patients with cancer-associated DIC, has been demonstrated in studies showing that therapeutic-dose LMWH can be safe and effective in preventing recurrence of thromboembolic episodes 1.
Quality of Life and Mortality Considerations
The management of DIC with heparin, as part of a comprehensive approach to address the underlying cause and provide supportive care, aims to improve patient outcomes in terms of morbidity, mortality, and quality of life. Given the high mortality rate associated with DIC, particularly when the underlying condition cannot be effectively treated, the use of heparin as a prophylactic therapy in appropriate cases is a critical component of care 1.
From the Research
Definition and Characteristics of DIC
- Disseminated intravascular coagulation (DIC) is an acquired clinicobiological syndrome characterized by widespread activation of coagulation leading to fibrin deposition in the vasculature, organ dysfunction, consumption of clotting factors and platelets, and life-threatening hemorrhage 2.
- DIC is a complex and serious condition characterized by both thrombosis and bleeding 2.
- It is a manifestation of an underlying pathologic process such as cancer, infection, trauma, or obstetric catastrophe 3.
Diagnosis of DIC
- The diagnosis of DIC should encompass both clinical and laboratory information 4.
- The International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system provides an objective measurement of DIC 4.
- Diagnosing DIC is challenging and relies on a combination of existing diagnostic criteria and laboratory tests 2.
Treatment of DIC
- The cornerstone of the treatment of DIC is treatment of the underlying condition 4, 3.
- Therapeutic strategies specific for DIC aim to control activation of blood coagulation and bleeding risk 5.
- Treatment strategies focus on addressing the underlying causes and may involve supportive care, anticoagulation therapy, and other supportive measures 2.
- 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 4.
Specific Treatment Approaches
- 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 4.
- Administration of fresh frozen plasma (FFP) may be useful in bleeding patients with DIC and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) 4.
- Severe hypofibrinogenaemia (<1 g/l) that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate 4.
- In cases of DIC where thrombosis predominates, therapeutic doses of heparin should be considered 4.