• Clinical science

Disseminated intravascular coagulation (Consumptive coagulopathy)

Summary

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. The most common causes of DIC include sepsis, trauma, and malignancy. Patients present with signs of bleeding (e.g., purpura, petechiae, ecchymoses) and/or multiorgan failure. Laboratory studies show thrombocytopenia, prolonged PT and aPTT, decreased fibrinogen levels, and increased D-dimer. Treatment involves identifying the underlying cause as well as supportive therapy with transfusions of platelet concentrates, FFP, and/or cryoprecipitate.

Etiology

The mnemonic “STOP Making Trouble!”- helps recall the etiology of DIC. M - Malignancy, T - Transfusion, S - Sepsis/Snakebites, T - Trauma (acute traumatic coagulopathy), O - Obstetric complications, P - PancreatitisReferences:[1][2]

Pathophysiology

Types of DIC Bleeding (hyperfibrinolytic) type Organ-failure (thrombotic) type Massive bleeding (consumptive) type Non-symptomatic DIC
Pathophysiology
  • Cytokines → hypercoagulation with hypofibrinolysis → microthrombi → impaired perfusion and tissue necrosis
Common causes
  • Any cause of DIC
Clinical features
  • 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

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

PT and APTT

×
Fibrinogen levels × ×
Factor V and factor VIII ×
Antithrombin

×

×

×

Hematocrit × × ×

Schistocytes

× ×

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!

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.
  • Shah PB. Intention-to-treat and per-protocol analysis. Can Med Assoc J. 2011; 183(6): pp. 696–696. doi: 10.1503/cmaj.111-2033.
  • Levi M, et al. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009; 145(1): pp. 24–33. doi: 10.1111/j.1365-2141.2009.07600.x.
  • Wada H, et al. Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines. Journal of Thrombosis and Haemostasis. 2013; 11(4): pp. 761–767. doi: 10.1111/jth.12155.
  • Di Nisio M, et al. Diagnosis and treatment of disseminated intravascular coagulation: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res. 2012; 129(5): pp. e177–e184. doi: 10.1016/j.thromres.2011.08.028.
  • Wada H, et al. Expert consensus for the treatment of disseminated intravascular coagulation in Japan. Thromb Res. 2010; 125(1). doi: 10.1016/j.thromres.2009.08.017.
  • Asakura H, et al. Proposal for new diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis. Thromb J. 2016; 14(1). doi: 10.1186/s12959-016-0117-x.
  • Taylor FB Jr, et al. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001; 86(5): pp. 1327–30. doi: 10.1055/s-0037-1616068.
  • Wada H, et al. Differences and similarities between disseminated intravascular coagulation and thrombotic microangiopathy. Thromb J. 2018; 16(1). doi: 10.1186/s12959-018-0168-2.
  • Papageorgiou C, et al. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clinical and Applied Thrombosis/Hemostasis. 2018; 24(9_suppl): pp. 8S–28S. doi: 10.1177/1076029618806424.
  • Boral BM, Williams DJ, Boral LI. Disseminated Intravascular Coagulation. Am J Clin Pathol. 2016; 146(6): pp. 670–680. doi: 10.1093/ajcp/aqw195.
last updated 06/19/2020
{{uncollapseSections(['jNc_a10', 'SNcy010', 'RNcla10', 'QNcua10', 'iNcJa10', '4Nc3Y10', '3NcSa10'])}}