Disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) results from inappropriate and excessive systemic activation of the coagulation system leading to generation of fibrin which causes deposition of microthrombi in microvasculature and larger vessels resulting in end organ damage.

Consumption of coagulation factors and platelets lead to bleeding. Levels of inhibitors of coagulation such as antithrombin, Protein C and Protein S are also reduced aggravating thrombin formation. Thus, patients with DIC may have simultaneous bleeding and thrombosis.

Common conditions that may lead to DIC include:

  • Sepsis
  • Malignancy eg. acute promyelocytic leukaemia, pancreatic cancer and ovarian cancer
  • Trauma
  • Obstetrics complications eg. preeclampsia, abruptio placentae, fetal death in utero
  • Acute heamolytic transfusion reaction in the setting of ABO-incompatible blood transfusion.

Acute DIC is a medical emergency and is always aimed towards eliminating the precipitating trigger (if possible) and treating any associated issues, such as infection or acidosis. Specialist advice is recommended.

In the presence of widespread bleeding, specific replacement with blood component therapy should be given.

Following initial replacement therapy, laboratory tests should be repeated. Any further treatment is guided by both clinical and laboratory responses.

Prothrombinex-VF is generally contraindicated as it may potentiate existing thrombotic tendency, which is a feature of patients with DIC. The role of heparin is controversial.

 

Blood Component Therapy in Disseminated Intravascular Coagulation

Fresh frozen plasma

  • When there is bleeding and abnormal coagulation

  • Usually 4 units (10–15 mL/kg) are rapidly infused
  • Is not indicated for chronic DIC

Cryoprecipitate

  • This contains fibrinogen in a concentrated form
    • Fibrinogen deficiency is commonly encountered in DIC
  • May be indicated at fibrinogen levels lower than 1.0 g/L and where there is clinical bleeding
    • Use to keep fibrinogen levels above 1.0 g/L

Platelets

  • May be appropriate when clinical bleeding and thrombocytopenia are considered major contributory factors
  • Usually 1–2 adult doses should be given

Thrombotrol-VF

  • Antithrombin (Thrombotrol-VF) replacement has also been used in some patients
  • May have a role in the management of those patients who do not respond to simple replacement therapy of blood components
  • Consult with a haematologist

 

References
  1. Levi, M., Toh, C. H., Thachil, J. and Watson, H. G. (2009), Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Journal of Haematology, 145: 24-33.