Disseminated Intravascular Coagulation

Aka: Disseminated Intravascular Coagulation, Disseminated Intravascular Coagulopathy, DIC

1. Causes
   1. Infection
      1. Gram NegativeSepsis
      2. Meningococcemia
      3. 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
2. Pathophysiology
   1. Intravascular fibrin deposition occludes small vessels
      1. Microemboli or thrombi form in vasculature
   2. Consumptive coagulopathy
      1. Widespread coagulation activation depletes factors
      2. Factors depleted
         1. Platelets
         2. Antithrombin III
         3. Protein C
         4. Tissue factor pathway inhibitor
3. Signs and symptoms
   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
4. 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 >40 seconds
   6. D-Dimer
      1. Early indicator of DIC in Preeclampsia
      2. Trofatter (1989) Obstet Gynecol 73:435-40
5. Labs: Monitoring (every 2 hours in DIC)
   1. Platelet Count
   2. Fibrinogen
6. 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 for platelets <20,000 to 40,000
      3. Fresh Frozen Plasma (preferred over Cryoprecipitate)
         1. Coagulation Factors
         2. Fibrinogen
   4. Heparin has been used in DIC (use is debated)
      1. Heparin continuous infusion at 300 to 500 IU/hour
7. References
   1. Levi (1999) N Engl J Med 341:586-92