Difference between revisions of "Disseminated intravascular coagulation"

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==Background==
 
==Background==
#Widespread and inappropriate activation of the coagulation and fibrinolytic systems
+
*Abbreviation = DIC
##Exposure of blood to procoagulants such as tissue factor and cancer procoagulant
+
*Widespread and inappropriate activation of the coagulation and fibrinolytic systems
##Formation of fibrin within the circulation
+
**Exposure of blood to procoagulants such as tissue factor and cancer procoagulant
##Fibrinolysis
+
**Formation of fibrin within the circulation
##Depletion of clotting factors
+
**Fibrinolysis
##End-organ damage
+
**Depletion of clotting factors
#Chronic DIC occurs when hepatic/bone marrow production balances coag factor consumption
+
**End-organ damage
 +
*Chronic DIC occurs when hepatic/bone marrow production balances coag factor consumption
  
==Causes==
+
===Causes===
#Infection
+
*[[Sepsis]](most common cause)
##Most common cause of DIC
+
*Carcinoma
##10%–20% of pts w/ Gram-neg sepsis have DIC
+
*[[Leukemia]]
###Septic pts more likely to have bleeding than thrombosis
+
*[[Trauma]]
##More likely to develop in asplenic pts or cirrhosis
+
*[[Pancreatitis]]
#Carcinoma
+
**Brain injury, [[crush injury]], [[burns]], [[rhabdomyolysis]], [[fat embolism]]
##DIC is often chronic and compensated
+
*[[hepatic failure|Liver disease]]
##Thrombosis is more common than bleeding
+
*[[Pregnancy]]-related
#Leukemia
+
**[[Placental Abruption]], [[Amniotic Fluid Embolus]], [[septic abortion]], [[HELLP Syndrome]], [[acute fatty liver of pregnancy]]
##More likely to have bleeding than thrombosis
+
*[[Snake bite]]
#Trauma
+
*[[ARDS]]
##Brain injury, crush injury, burns, rhabdo, fat embolism
+
*[[Transfusion reaction]]
#Liver disease
+
*[[Transplant complications|Transplant rejection]]
##May have chronic compensated DIC; acute DIC may occur in setting of acute liver failure
 
#Pregnancy
 
##Abruption, [[Amniotic Fluid Embolus]], septic abortion, HELLP syndrome
 
#Envenomation
 
##Rattlesnakes and other vipers
 
##Bleeding not as serious as expected from lab values
 
#ARDS
 
##20% of pts with ARDS develop DIC; 20% of pts with DIC develop ARDS
 
#Transfusion reactions
 
  
 
==Clinical Features==
 
==Clinical Features==
*In given pt either bleeding or thrombosis will predominate
+
''[[hemorrhage|Bleeding]] or [[thromboembolism|thrombosis]] can predominate (bleeding is more common ~65%)''
**Bleeding is more common (65% of pts)
+
*[[Shoc]]k (15%)
***Ranges from petechiae/ecchymosis to life-threatening GI/CNS/pulm bleeding
+
*[[Acute renal failure]] (25-40%)
***Shock occurs in 15%
+
*[[hepatic failure|Hepatic dysfunction]] (19%)
**Renal failure (25-40%)
+
*Respiratory dysfunction (16%)
**Hepatic dysfunction (19%)
+
*[[Thromboembolism]] (7%)
**Respiratory dysfunction (16%)
+
*CNS involvement (2%)
**Thromboembolism (7%)
+
*[[Purpura fulminans]] (widespread arterial and venous thromboses)
**CNS involvement (2%)
+
**Associated with significant [[bacteremia]]
**Purpura fulminans (widespread arterial and venous thromboses)
 
***Associated w/ significant bacteremia
 
  
==Diagnosis==
+
==Differential Diagnosis==
#Acute DIC
+
{{Hemolytic anemia DDX}}
##Platlets
+
{{Thrombocytopenia}}
###Low (or dropping)
+
{{Increased bleeding DDX}}
###Sn, not Sp
+
{{Bullous rashes DDX}}
##PT
 
###Prolonged
 
##Fibrinogen
 
###Low
 
###<100 correlates w/ severe DIC
 
###May be normal (acute phase reactant)
 
##PTT
 
###Prolonged
 
##FDP
 
###Elevated
 
##D-dimer
 
###Elevated
 
###Sn but not Sp: may also see in pts w/ chronic liver or renal disease
 
##RBCs
 
###Fragmented (not specific)
 
#Chronic DIC
 
##FDP: Elevated
 
##D-dimer: Elevated
 
##Platelet: Variable
 
##Fibrinogen: Normal-elevated
 
##PT: Normal
 
##PTT: Normal
 
##RBCs
 
###Fragmented
 
  
==DDX==
+
==Evaluation==
#[[TTP]]-[[HUS]]
+
===Acute===
##Pts usually have little or no prolongation of PT or PTT
+
*Platelets<ref>Spero JA, Lewis JH, Hasiba U. Disseminated intravascular coagulation. Findings in 346 patients. Thromb Haemost. 1980 Feb 29. 43(1):28-33.</ref>
#Severe liver disease
+
**[[thrombocytopenia|Low]] (or dropping) in 98% of DIC patients
##Also a/w prolonged PT/PTT, thrombocytopenia, incr D-dimer, incr FDPs
+
**Sn, not Sp
###However, D-dimer is usually only mildly elevated
+
**Repeat platelets may be necessary if first level normal or if need to trend
#Heparin-induced thrombocytopenia
+
*PT and PTT
 +
**[[coagulopathy|Prolonged]]
 +
**May be normal in as many as 50% of DIC patients<ref>Olson JD, Kaufman HH, Moake J, O'Gorman TW, Hoots K, Wagner K, et al. The incidence and significance of hemostatic abnormalities in patients with head injuries. Neurosurgery. 1989 Jun. 24(6):825-32.</ref>
 +
**Serial coagulation testing may be necessary
 +
**PT, not INR, is used for monitoring<ref>Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009 Apr. 145(1):24-33.</ref>
 +
*Fibrinogen
 +
**Low
 +
**<100 correlates with severe DIC
 +
**May be normal (acute phase reactant), up to 57% in  DIC patients<ref>Spero JA, Lewis JH, Hasiba U. Disseminated intravascular coagulation. Findings in 346 patients. Thromb Haemost. 1980 Feb 29. 43(1):28-33.</ref>
 +
*FDP
 +
**Elevated
 +
*[[D-dimer]]
 +
**Elevated
 +
**Sn but not Sp: may also see in patients with chronic liver or renal disease
 +
**Combination of elevated FDP and d-dimer may increase sensitivity and specificity
 +
*RBCs
 +
**Fragmented (not specific)
  
==Treatment==
+
===Chronic===
#Treat underlying illness
+
*FDP: Elevated
#Replacement tx
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*[[D-dimer]]: Elevated
##Only indicated in pts w/ documented DIC + bleeding or impending procedure
+
*Platelet: Variable
###Fibrinogen
+
*Fibrinogen: Normal-elevated
####Consider repletion w/ cryoprecipitate to raise level to 100-150
+
*PT: Normal
###Platelets
+
*PTT: Normal
####Consider repletion if <50K w/ bleeding or <20K without bleeding
+
*RBCs
###FFP
+
**Fragmented
###Vitamin K
+
 
###Folate
+
==Management==
##Heparin
+
*Treat underlying illness
###Consider only in pts w/ thromboembolic predominant symptoms from chronic DIC
+
*Replacement treatment
 +
**Only indicated in with documented DIC + bleeding or impending procedure
 +
***Fibrinogen
 +
****Consider repletion with [[cryoprecipitate]] to raise level to 100-150
 +
***[[Platelets]]
 +
****Consider repletion if <50K with bleeding or <20K without bleeding
 +
***[[FFP]]
 +
****Consider repletion to goal of PT and PTT < 1.5 times the normal limit
 +
***[[Vitamin K]]
 +
***[[Folate]]
 +
**[[Heparin]]
 +
***Consider only if thromboembolic are predominant symptoms from chronic DIC
 +
 
 +
==Disposition==
 +
*Admit
  
 
==See Also==
 
==See Also==
 
*[[Coagulopathy (Main)]]
 
*[[Coagulopathy (Main)]]
  
==Source ==
+
==References==
Tintinalli
+
<references/>
 
 
 
[[Category:Heme/Onc]]
 
[[Category:Heme/Onc]]

Latest revision as of 00:24, 1 October 2019

Background

  • Abbreviation = DIC
  • Widespread and inappropriate activation of the coagulation and fibrinolytic systems
    • Exposure of blood to procoagulants such as tissue factor and cancer procoagulant
    • Formation of fibrin within the circulation
    • Fibrinolysis
    • Depletion of clotting factors
    • End-organ damage
  • Chronic DIC occurs when hepatic/bone marrow production balances coag factor consumption

Causes

Clinical Features

Bleeding or thrombosis can predominate (bleeding is more common ~65%)

Differential Diagnosis

Microangiopathic Hemolytic Anemia (MAHA)

Thrombocytopenia

Decreased production

Increased platelet destruction or use

Drug Induced

Comparison by Etiology

ITP TTP HUS HIT DIC
↓ PLT Yes Yes Yes Yes Yes
↑PT/INR No No No +/- Yes
MAHA No Yes Yes No Yes
↓ Fibrinogen No No No No Yes
Ok to give PLT Yes No No No Yes

Coagulopathy

Platelet Related

Factor Related

Vesiculobullous rashes

Febrile

Afebrile

Evaluation

Acute

  • Platelets[1]
    • Low (or dropping) in 98% of DIC patients
    • Sn, not Sp
    • Repeat platelets may be necessary if first level normal or if need to trend
  • PT and PTT
    • Prolonged
    • May be normal in as many as 50% of DIC patients[2]
    • Serial coagulation testing may be necessary
    • PT, not INR, is used for monitoring[3]
  • Fibrinogen
    • Low
    • <100 correlates with severe DIC
    • May be normal (acute phase reactant), up to 57% in DIC patients[4]
  • FDP
    • Elevated
  • D-dimer
    • Elevated
    • Sn but not Sp: may also see in patients with chronic liver or renal disease
    • Combination of elevated FDP and d-dimer may increase sensitivity and specificity
  • RBCs
    • Fragmented (not specific)

Chronic

  • FDP: Elevated
  • D-dimer: Elevated
  • Platelet: Variable
  • Fibrinogen: Normal-elevated
  • PT: Normal
  • PTT: Normal
  • RBCs
    • Fragmented

Management

  • Treat underlying illness
  • Replacement treatment
    • Only indicated in with documented DIC + bleeding or impending procedure
      • Fibrinogen
      • Platelets
        • Consider repletion if <50K with bleeding or <20K without bleeding
      • FFP
        • Consider repletion to goal of PT and PTT < 1.5 times the normal limit
      • Vitamin K
      • Folate
    • Heparin
      • Consider only if thromboembolic are predominant symptoms from chronic DIC

Disposition

  • Admit

See Also

References

  1. Spero JA, Lewis JH, Hasiba U. Disseminated intravascular coagulation. Findings in 346 patients. Thromb Haemost. 1980 Feb 29. 43(1):28-33.
  2. Olson JD, Kaufman HH, Moake J, O'Gorman TW, Hoots K, Wagner K, et al. The incidence and significance of hemostatic abnormalities in patients with head injuries. Neurosurgery. 1989 Jun. 24(6):825-32.
  3. Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009 Apr. 145(1):24-33.
  4. Spero JA, Lewis JH, Hasiba U. Disseminated intravascular coagulation. Findings in 346 patients. Thromb Haemost. 1980 Feb 29. 43(1):28-33.