Coags

Disseminated Intravascular Coagulation

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Disseminated Intravascular Coagulation, Disseminated Intravascular Coagulopathy, DIC

  • Pathophysiology
  1. Intravascular fibrin deposition occludes small vessels
    1. Microemboli or thrombi form in vasculature
  2. Consumptive Coagulopathy
    1. 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
  • Causes
  1. Infection
    1. Sepsis (most common)
    2. Gram NegativeSepsis
    3. Meningococcemia
    4. Rocky Mountain Spotted Fever
  2. Neoplastic disease
    1. Mucin-Secreting adenocarcinoma
    2. Promyelocytic Leukemia
    3. Prostate Cancer
    4. Lung Cancer
  3. Tissue Damage
    1. Trauma
    2. Surgery (e.g. Prostate Surgery)
    3. Heat Stroke
    4. Burn Injury
    5. Dissecting aneurysm
  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)
  6. Immunologic Disorders
    1. Immune complex disorders
    2. Allograft rejection
    3. Incompatible Blood Transfusion
    4. 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
    6. Cavernous Hemangioma
  • Signs
  1. Profuse bleeding from many sites
    1. Needle puncture site bleeding
    2. Mucosal bleeding
    3. Surgical incision or Laceration bleeding
    4. 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
  • Labs
  • Initial
  1. Platelet Count <100,000/mm3
  2. Fibrinogen <300 mg/dl
  3. Fibrin split product >40 mg/dl
  4. Prothrombin Time (aPT) >14 seconds or INR increased
  5. Partial Thromboplastin Time (PTT) >40 seconds
  6. D-Dimer
    1. Early indicator of DIC in Preeclampsia
    2. Trofatter (1989) Obstet Gynecol 73:435-40 [PubMed]
  • Labs
  • Monitoring (every 2 hours in DIC)
  • 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. 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
  • References
  1. Shinke and Ponce (2016) Crit Dec Emerg Med 30(8):13
  2. Levi (1999) N Engl J Med 341:586-92 [PubMed]