Disseminated Intravascular Coagulation (DIC)

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Diagnosis and treatment of disseminated intravascular coagulation (DIC) according to four DIC guidelines

  • Result of excessive activation of both hemostatic and fibrinolytic pathways that overwhelm physiological inhibitors: tissue injury results from disseminated microvascular thrombosis, bleeding results from consumption of coagulation factors and platelets & from systemic fibrinolysis.
  • Causes include: Infection/Sepsis, Malignancy (especially Acute Promyelocytic Leukemia), Trauma, Obstetrical Complications, Intravascular Hemolysis (ABO or other major RBC antigen incompatibility), Heat Stroke, Crush Injury, Amphetamine overdose, Fat Embolism, Snake Bites, Burns, Head injuries, Cardiac Arrest/Shock
  • DDx: Chronic DIC, TTP, Primary Hyperfibrinolysis, HELLP, Severe hepatic cirrhosis
  • Diagnosis of DIC is based upon clinical scenario supported by laboratory findings
    • Thrombosis may manifest as ecchymoses that can progress to purpura fulminans, cold pulseless limbs, sudden loss of vision or other neurological insults
    • Bleeding may manifest from incisions, mucosal membranes, IV sites, urinary tract
  • Laboratory features:

International Society for Thrombosis and Hemostasis (ISTH) Scoring System

Test Result Points
Platelet count > 100,000/mL 0
51-99/mL 1
≤ 50/mL 2
PT < 3 seconds 0
3-6 seconds 1
> 6 seconds 2
Fibrinogen > 100 mg/dL 0
< 100 mg/dL 1
Fibrin-related markers (D-dimer) No increase 0
Moderate increase 2
Strong increase 3

Interpretation:    <5 Non-overt DIC

>5 Severe DIC (93% sensitivity, 98% specificity)

  • Management:
    • TREAT UNDERLYING CAUSE
      • Do not delay interventions in order to correct coagulopathy
    • Heparin may be of benefit in DIC when thrombosis (and not hemorrhage) is prominent
    • Transfusion support indicated only in hemorrhaging patients
      • Do not transfuse for abnormal laboratory values (including fibrinogen) if no bleeding is present
      • Replacement therapy should focus on platelets and fibrinogen initially, coagulation factors secondarily

Platelet transfusion indicated for platelet counts <50,000/mL, cryoprecipitate for fibrinogen < 100 mg/dL.

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