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disseminated intravascular coagulation (DIC)

DIC results from activation of the coagulation & fibrinolytic systems. It occurs in conditions which promote tissue factor release. DIC may be acute or chronic. Patients with chronic DIC present with bleeding such as epistaxis or gingival bleeding; the condition is problematic, but not life threatening as is acute DIC. Etiology: 1) obstetric a) amniotic fluid embolism b) abruptio placentae c) eclampsia d) uterine rupture e) retained placental products f) dead fetus g) septic or missed abortion 2) tissue injury a) trauma (head injury or crush injury) b) severe burns c) surgery d) hypothermia e) hyperthermia f) anoxia or asphyxia g) ischemia or infarction 3) immunologic a) anaphylaxis b) hemolytic transfusion reaction c) drug reaction d) autoimmune vasculitis 4) pulmonary a) adult respiratory distress syndrome (ARDS) b) pulmonary embolism c) pulmonary infarction 5) infection a) bacterial infection: Gm-, Gm+, anaerobes b) Mycobacterial infection c) viral infection: CMV, Varicella zoster, hepatitis d) Rickettsial infection e) fungal infection: Aspergillus, Candida, Histoplasmosis f) protozoan infection: malaria 6) malignancy a) acute leukemia, especially acute promyelocytic leukemia b) solid tumors, especially adenocarcinomas 1] pancreatic carcinoma 2] prostate carcinoma c) chronic DIC is generally associated with malignancy -> Trousseau's syndrome 7) cardiovascular a) acute myocardial infarction b) vascular surgery c) peripheral vascular disease d) shock 8) miscellaneous a) liver disease, acute & chronic b) envenomation 1] snake bite 2] brown recluse spider bite c) embolism d) amyloidosis e) SGLT2 inhibitors (serum glucose may be normal) Pathology: 1) initiation a) release of tissue factor or generation of tissue factor on the surface of endothelial cells & monocytes b) release of tumor necrosis factor c) IL-1 release d) endotoxin release e) placental tissue substances 2) activation of extrinsic pathway of coagulation a) excessive formation of thrombin & plasmin b) formation & breakdown of fibrin c) clot formation & breakdown d) depletion of coagulation factors & platelets e) microvascular fibrin deposition f) microangiopathic hemolysis Clinical manifestations: 1) bleeding a) bleeding at site of wound b) gingival bleeding c) vascular access site oozing d) epistaxis 2) petechiae 3) echymosis 4) hemorrhagic bullae 6) gangrene 7) purpura: purpura fulminans 8) acral cyanosis 9) hematuria 10) thromboses (chronic), venous or arterial 11) skin infarction Laboratory: 1) platelets in plasma < 60,000/mm3 (thrombocytopenia) 2) PT & aPTT may be prolonged or normal, INR may be elevated 3) increased fibrin degradation products a) elevated D-dimer b) diminished plasma fibrinogen - may be elevated with inflammatory process - progressively diminishes with DIC 4) microangiopathic anemia - schistocytosis in peripheral smear (30-50%) [2] 5) elevated factor VIII activity rules out DIC [2] 5) see ARUP consult [2] Differential diagnosis: 1) vitamin K deficiency 2) renal failure 3) dysfibrinogenemia 4) systemic lupus erythematosus 5) thrombotic thrombocytopenic purpura (TTP) - acute renal failure, mental status changes, elevated indirect bilirubin 6) liver disease - normal or elevated factor VIII activity suggests liver failure [2] - factor V not consumed during DIC - DIC often co-eixsts with liver disease [2] 7) sickle cell crisis 8) sepsis Management: 1) acute DIC a) treatment of underlying pathology b) fresh frozen plasma - 10-15 mL/kg - aim for PT within 2-3 seconds of control c) cryoprecipitate: - indicated for hypofibrinogenemia - 0.2 bags/kg, 1-12 bags for 70 kg person d) platelet transfusion - platelets < 10,000-20,000/mm3 - platelets < 50,000/mm3 with major bleeding e) heparin - indications: - amniotic fluid embolism - aortic aneurysm - evidence of thrombosis - transfusion reaction - neoplasm - contraindications - CNS injury - fulminant liver failure - obstetric accidents - administration - 80-100 units/kg SC every 4-6 hours - 5-10 units/kg/hour IV drip 2) chronic DIC a) treatment of underlying pathology b) low dose subcutaneous heparin c) combination antiplatelet agents - aspirin 600 mg BID with 30 mL of liquid antacid plus dipyridamole 50 mg QID - sulfinpyrazone 200 mg BID with 30 mL of liquid antacid plus dipyridamole 50 mg QID

Related

localized intravascular coagulation Trousseau's syndrome; Trousseau's sign of malignancy; thrombophlebitis migrans

General

hypercoagulability sign/symptom intravascular coagulation

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 617-618
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018.
  3. Schiller G, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  4. ARUP Consult: Disseminated Intravascular Coagulation - DIC The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/disseminated-intravascular-coagulation