Disseminated Intravascular Coagulation

Haemostasis

COAGULATION FIBRINOLYSIS

DIC

• an acquired syndrome

• intravascular activation of coagulation leading to consumptive coagulopathy

• causing damage to the microvasculature and organ dysfunction

(International Society of Thrombosis and Hemostasis [ISTH]).

DIC

• A dynamic condition triggered by variety of stimuli

• Require serial testing and clinical assessment

• No formula/ specific regimes

• Therapy must be individualized, tailored to patient specific needs

Clinical assessment

• Identify the underlying cause

• Identify possible DIC– Bleeding from more than one site

– Uncontrolled bleeding from puncture sites

– Thrombosis and Multi Organ Dysfunction

• Clinical picture ranges from major haemorrhage with or without thrombosis to a clinically stable state that can only be detected by laboratory testing.

Identify the underlying cause

Identify the underlying cause

Laboratory investigations

No single test that can establish or rule out DIC.

Dynamic situation and a single test reflects only at that time point.

• Coagulation profile

• PT and aPTT– Shows the degree of

coagulation factor consumption & activation

– Early can be shortened, normal

– Late -prolonged

• Fibrinogen- low < 1g/l– Acute phase protein ( falsely

normal)

• Fibrin Degradation Products

• D-Dimers– Shows the extent of fibrin

formation

• Thombin time

• FBP- Microangiopathic Haemolytic Anemia (MAHA)

• Plt- thrombocytopenia

Management of DIC

TREAT THE UNDERLYING CAUSE

Management of DIC

• Stabilize haemodynamically (ABC), correct acidosis

• Manage clinically with the assistance of laboratory support

• Judicious blood products if bleeding

• Consider heparin/ LMWH

• ?Role of antifibrinolytic agents (tranexamic acid) in special situations

Blood products

Role of blood products• Judicious use of blood products in bleeding

situations

• Don’t just treat the lab results!

• Needs correlation with clinical findings.

• May worsen the thrombotic manifestations of DIC

Role of blood products in treatment of DIC

• RBCs

• Platelets

• FFP

• Cryoprecipitate

• Keep hemoglobin in range of 8 to 10 g/dL

• Depends on risks for bleeding, not just the platelet count. >50,000/μL

• Enormously overrated in treatment of DIC, especially since recent evolution of our understanding and danger of TRALI. Some indication to supplement RBC transfusions in “total body exchange” situations

• Probably best source of fibrinogen. Reasonable target is to keep fibrinogen levels between 50 and 100 mg/dL

‘DIC regime’

6 units of cryoprecipitate

+ 4 units of platelets

+ 2 units of FFP

‘DIC regime’

6 units of cryoprecipitate

+ 4 units of platelets

+ 2 units of FFP

Pitfalls in DIC regime

• One size fits all ? 40 kg vs 80kg pt

• More concern about preventing coagulopathy than replacing blood loss

• Forget to transfuse PRBC!

• On receipt of DIC regime, transfusing platelets, FFP, Cryoprecipitate and lastly PRBC which is the one most needed

• Request DIC regime early without sending a DIC screen

Thank you