• Clinical science

Disseminated intravascular coagulation (Consumptive coagulopathy)

Abstract

Disseminated intravascular coagulation (DIC) is a disorder characterized by systemic activation of the clotting cascade with microthrombi formation, platelet consumption, and subsequent exhaustion of all clotting factors, which causes hemorrhagic manifestations. The most common causes are sepsis, trauma, and malignancy. Patients present with bleeding manifestations (e.g., purpura), and/or signs of multiorgan failure. Laboratory studies show thrombocytopenia, prolonged PT and aPTT, decreased fibrinogen levels, and increased D-dimer. Treatment of DIC involves treatment of the underlying cause, and supportive therapy with transfusions of platelet concentrates, FFP, and/or cryoprecipitate.

Etiology

Thrombokinase-rich organs: Pulmonary, Prostate, Pancreas, Placenta


References:[1][2]

Epidemiology

  • Incidence: 1% of all hospital admissions

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiology

Types of DIC Bleeding (hyperfibrinolytic) type Organ-failure (thrombotic) type Massive bleeding (consumptive) type Non-symptomatic DIC
Pathophysiology
  • Cytokines Plasminogen activator inhibitor-I (PAI-I) and neutrophil extracellular traps (NETs) → hypercoagulation with hypofibrinolysis → platelet and fibrin-rich microthrombi → impaired perfusion and tissue necrosis
Common causes
  • Any cause of DIC
Clinical manifestation
  • Bleeding
  • Massive hemorrhage
  • Asymptomatic

DIC is an acquired coagulopathy that is frequently seen in hospitalized individuals!


References:[3][4]

Clinical features

The clinical features of DIC may appear acutely (e.g., following trauma, sepsis), or may appear subacutely (e.g., DIC following malignancy)!
References:[1][2]

Diagnostics

ISTH criteria Score
0 1 2 3
Platelet count > 100,000 /mm3 50,000–100,000 /mm3 < 50,000 /mm3 ×
Increase in fibrin markers (D-dimer, or FDP) None × Moderate Strong
Prothrombin time < 3 seconds 3–6 seconds > 6 seconds ×
Fibrinogen > 1 g/dL < 1 g/dL × ×
  • Presence of an underlying disorder and ISTH score ≥ 5: DIC likely → monitor daily
  • Presence of an underlying disorder and ISTH score < 5: probable DIC → repeat monitoring in 1–2 days

The diagnosis of DIC is not based on a single marker but on a combination of laboratory findings! Thrombocytopenia, elevated D-dimer, increased PT and aPTT, and low fibrinogen should immediately raise suspicion for DIC!

Finding Type of DIC Differential diagnosis
Bleeding type Organ failure type Consumptive type Non-symptomatic type
Thrombocytopenia bleeding time
↑ Markers of fibrin breakdown (D-dimer, or FDP)

PT and APTT

×
Biphasic APTT waveform × × ×
  • Infection
Fibrinogen levels × ×
  • Hepatic dysfunction
Antithrombin

×

×

×

  • Hepatic dysfunction
  • Capillary leak syndrome
↑ Soluble fibrin, ↑ Thrombin-antithrombin complex
Plasmin α2-plasmin inhibitor complex (PPIC) × ×
Hematocrit × × ×
Schistocytes × ×

References:[3][4][5]

Differential diagnoses

All coagulation factors would be decreased in patients with DIC!
References:[1][2]

The differential diagnoses listed here are not exhaustive.

Treatment

Treatment of the underlying disease forms the cornerstone of the management of DIC!


References:[1][3][6]

  • 1. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Education; 2015.
  • 2. Levi MM. Disseminated Intravascular Coagulation. In: Nagalla S. Disseminated Intravascular Coagulation. New York, NY: WebMD. http://emedicine.medscape.com/article/199627. Updated September 29, 2016. Accessed March 27, 2017.
  • 3. Wada H, Matsumoto T, Yamashita Y. Diagnosis and treatment of disseminated intravascular coagulation (DIC) according to four DIC guidelines. J Intensive Care. 2014; 2(1): p. 15. doi: 10.1186/2052-0492-2-15.
  • 4. Asakura H. Classifying types of disseminated intravascular coagulation: clinical and animal models. J Intensive Care. 2014; 2(1): p. 20. doi: 10.1186/2052-0492-2-20.
  • 5. Lesesve J-F, Martin M, Banasiak C, et al. Schistocytes in disseminated intravascular coagulation. Int J Lab Hematol. 2013; 36(4): pp. 439–443. doi: 10.1111/ijlh.12168.
  • 6. Ruiz C, Andresen M. Treatment of acute coagulopathy associated with trauma. ISRN Critical Care. 2013; 2013: pp. 1–7. doi: 10.5402/2013/783478.
last updated 08/31/2018
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