Disseminated intravascular coagulation

OVERVIEW

  • Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by the intravascular activation of coagulation with loss of localization arising from different causes
  • It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction

PATHOPHYSIOLOGY

  • underlying disease process
    -> pro-inflammatory cytokines (activation of mononuclear and endothelial cells)
    -> intravascular fibrin formation
    -> microvascular thrombi and organ dysfunction
    -> consumptive intravascular coagulopathy and thrombocytopenia
    -> widespread haemorrhage

CAUSES

Include:

  • shock
  • sepsis
  • haemolysis
  • malignancy (e.g. promyelocytic leukaemia, other hematological malignancies, solid tumors)
  • trauma (e.g. multi-trauma, TBI, fat embolism syndrome)
  • pancreatitis
  • severe hepatic failure
  • burns
  • major surgery
  • PE
  • ECMO
  • transplant rejection
  • transfusion reactions
  • obstetric: pre-eclampsia, amniotic fluid embolism, intrauterine death, abruption
  • vascular disorders (e.g. Kasabach-Merrit syndrome, large aneurysms)

CLINICAL FEATURES

  • may be chronic with little overt clinical effects
  • can be an acute catastrophe
  • haemorrhage
  • microthrombosis leading to multiorgan failure

INVESTIGATIONS

  • anaemia
  • prolonged APTT, INR and PT
  • thrombocytopaenia (or falling platelets)
  • low fibrinogen
  • fragmented RBCs on blood film
  • high fibrin degradation products (FDPs) / D-dimer
  • low levels of plasma coagulation factors and inhibitors (if tested)

DIC score (Taylor et al, 2001)

  • useful for diagnosis of DIC
  • simple scoring system based on platelet count, PT, D-dimer levels and fibrinogen
  • sensitivity 93% and specificity 98%
  • strong independent predictor of mortality in patients with severe sepsis

DIFFERENTIAL DIAGNOSIS

Other important causes of prolonged APTT, INR and PT and low fibrinogen include:

  • Primary fibrinolysis
  • ‘Dilutional coagulopathy’ from massive transfusion
  • Trauma-induced coagulopathy
  • Post thrombolysis
  • Venom-induced consumptive coagulopathy (VICC) from snake bite envenoming

MANAGEMENT

  • treat cause!
  • FFP for APTT and INR
  • cryoprecipitate for fibrinogen (>1.0)
  • platelets for thrombocytopaenia (aim > 50)
  • consider FIIa
  • consider heparin if not bleeding (in chronic DIC)

References and Links

  • Levi M, Opal SM. Coagulation abnormalities in critically ill patients. Crit Care. 2006;10(4):222. PMC1750988.
  • Taylor FBJ, Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost.2001;86:1327–1330. PMID: 11816725

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.