Disseminated Intravascular Coagulation

Aka: Disseminated Intravascular Coagulation, Disseminated Intravascular Coagulopathy, DIC

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II. Pathophysiology

  1. Consumptive Coagulopathy
    1. Uninhibited, widespread coagulation activation breaks down formed clot and depletes factors
    2. Results in both bleeding and clotting
    3. Factors depleted
      1. Platelets
      2. Antithrombin III
      3. Protein C
      4. Tissue factor pathway inhibitor
  2. Clotting (microvascular)
    1. Intravascular Fibrin deposition occludes small vessels
    2. Microemboli or thrombi form in vasculature
  3. Bleeding
    1. Results from uncontrolled Clotting Factor and Platelet consumption
  4. Final pathway
    1. Multiorgan failure

III. Causes

  1. Infection
    1. Sepsis (most common)
    2. Gram NegativeSepsis
    3. Meningococcemia
    4. Rocky Mountain Spotted Fever
    5. Viral Hemorrhagic Fever
    6. Malaria
  2. Neoplastic disease
    1. Mucin-Secreting adenocarcinoma
    2. Acute promyelocytic Leukemia
    3. Acute Lymphoblastic Leukemia
    4. Acute Myeloid Leukemia
    5. Prostate Cancer
    6. Lung Cancer
    7. Other solid tumors
  3. Tissue Damage
    1. Trauma
    2. Surgery (e.g. Prostate Surgery)
    3. Heat Stroke
    4. Burn Injury
    5. Dissecting aneurysm
    6. Rhabdomyolysis
  4. Obstetrical Complication
    1. Abruptio Placentae
    2. Amniotic Fluid Embolism
    3. Retained fetal products on intrauterine fetal death
    4. Severe Preeclampsia
    5. HELLP Syndrome
    6. Acute Fatty Liver of Pregnancy
  5. Hemolytic disease
    1. Thrombotic Thrombocytopenic Purpura (TTP)
    2. Hemolytic Uremic Syndrome (HUS)
    3. Transfusion Hemolysis (Incompatible Blood Transfusion)
  6. Immunologic Disorders
    1. Immune complex disorders
    2. Allograft rejection
    3. Anaphylaxis
  7. Metabolic
    1. Diabetic Ketoacidosis
  8. Miscellaneous
    1. Shock
    2. Snake Bite
    3. Cyanotic Congenital Heart Disease
    4. Fat embolism
    5. Severe liver disease (e.g. Cirrhosis)
    6. Acute Liver Disease or Acute Hepatitis
    7. Cavernous Hemangioma (or giant Hemangioma)

IV. Signs

  1. Profuse bleeding from many sites
    1. Needle puncture site bleeding
    2. Oozing from the insertion sites of inserted tubes, lines and drains
    3. Mucosal bleeding including Gastrointestinal Bleeding and Gingival Bleeding
    4. Surgical incision or Laceration bleeding
    5. Multiple Bruises or Petechiae
  2. Thrombosis
    1. End organ ischemia or infarction
    2. Multi-system failure
  3. Associated conditions
    1. Acute Tubular Necrosis
    2. Adult Respiratory Distress Syndrome
    3. Purpura fulminans

V. Labs: Initial

  1. See ISTH DIC Score
  2. Platelet Count <100,000/mm3
  3. Fibrinogen <300 mg/dl
  4. Fibrin split product >40 mg/dl
  5. Prothrombin Time (aPT) >14 seconds or INR increased
  6. Partial Thromboplastin Time (PTT) >40 seconds
  7. D-Dimer
    1. Early indicator of DIC in Preeclampsia
    2. Trofatter (1989) Obstet Gynecol 73:435-40 [PubMed]

VI. Labs: Monitoring (every 2 hours in DIC)

  1. Platelet Count
  2. Fibrinogen

VII. Management

  1. Supportive care
    1. ABC Management
    2. Cardiopulmonary support
  2. Treat underlying disorder
    1. Example: Delivery in pregnancy related DIC
    2. Example: Antibiotics in Sepsis
  3. Transfuse Blood Products as needed
    1. Packed Red Blood Cells
    2. Platelet Transfusion
      1. Indicated in Platelet Count <20,000 without active bleeding (<50,000 with active bleeding)
      2. Goal Platelet Count >50,000/mm3
    3. Fresh Frozen Plasma (preferred over Cryoprecipitate) to supply Coagulation Factors, Fibrinogen
      1. Goal PT/INR and PTT <1.5x normal
    4. Avoid harmful measures
      1. Do not administer anti-Fibrinolytic agents (e.g. Tranexamic Acid)
      2. Heparin use is controversial
  4. Heparin has been used in DIC (use is debated)
    1. Heparin continuous infusion at 300 to 500 IU/hour

VIII. References

  1. Shinke and Ponce (2016) Crit Dec Emerg Med 30(8):13
  2. Jones (2024) Am Fam Physician 110(1): 58-64 [PubMed]
  3. Levi (1999) N Engl J Med 341:586-92 [PubMed]

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