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Disseminated intravascular coagulation

Definition
DIC is a clinicopathologic syndrome characterized by systemic activation of widespread coagulation resulting in severe bleeding and organ failure.
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Pathophysiology
DIC is mostly caused by hypercoagulation (infection, particularly sepsis) and hyperfibrinolysis (acute promyelocytic leukemia, obstetric diseases, or aortic aneurysms).
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Epidemiology
The incidence of DIC in the US is estimated at 18.6 cases per 100,000 person-years.
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Disease course
Clinical manifestations include latent and compensated activation of coagulation (no obvious clinical symptoms) and overt DIC (microvascular thrombosis, multi-organ dysfunction, macrovascular thrombi resulting in venous or arterial obstruction and embolization). Sustained thrombin generation results in severe bleeding and an increased risk of death.
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Prognosis and risk of recurrence
The in-hospital mortality of DIC in critically ill patients is 45%.
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Key sources
The following summarized guidelines for the evaluation and management of disseminated intravascular coagulation are prepared by our editorial team based on guidelines from the International Society on Thrombosis and Haemostasis (ISTH 2015; 2013), the Italian Society for Haemostasis and Thrombosis (SISET 2012), and the British Committee for Standards In Haematology (BCSH 2009).
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Guidelines

1.Screening and diagnosis

Diagnosis: as per ISTH 2013 guidelines, recognize that there is no gold standard for the diagnosis of DIC and a single test that is, by itself, capable of accurately diagnosing DIC.
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2.Classification and risk stratification

Scoring systems: as per ISTH 2013 guidelines, use a scoring system for the diagnosis of DIC, recognizing that the ISTH score correlates with key clinical observations and outcomes.
B

3.Diagnostic investigations

Laboratory tests
Avoid using stand-alone laboratory tests in patients with suspected DIC.
D
Consider obtaining D-dimer as a fibrin-related marker considering an increase up to 10 times the ULN as moderate and an increase above this threshold as strong.
C

4.Medical management

General principles: as per ISTH 2013 guidelines, treat the underlying condition as the cornerstone of treatment of DIC.
B

More topics in this section

  • PCC

  • Fibrinogen replacement

  • Recombinant factor VIIa

  • Activated protein C

  • Intravenous heparin

  • Antithrombin concentrate

  • Recombinant thrombomodulin

  • Dermatan sulfate and gabexate

  • Antifibrinolytic agents

5.Inpatient care

Thromboprophylaxis: as per ISTH 2013 guidelines, administer prophylaxis for VTE with prophylactic doses of UFH
B
or LMWH in critically ill, non-bleeding patients with DIC, recognizing that there is no direct evidence of the effects of anticoagulants on DIC.
A

6.Therapeutic procedures

Indications for transfusion therapy
Consider performing transfusion (platelets, plasma, cryoprecipitate) in patients with DIC and active bleeding.
C
Avoid performing transfusion solely based on laboratory parameters in patients with chronic DIC or without active bleeding.
D

More topics in this section

  • Platelet transfusion

  • FFP transfusion

  • Plasmapheresis

7.Specific circumstances

Patients with malignancy: consider administering platelets to maintain a platelet count > 50×10⁹/L in patients with DIC and active bleeding.
C
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8.Follow-up and surveillance

Serial laboratory assessment: as per ISTH 2013 guidelines, obtain repeated tests to monitor the dynamic changes based on laboratory results and clinical observations.
B