Difference between revisions of "Disseminated intravascular coagulation"

 
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===Causes===
 
===Causes===
*Infection (most common cause)
+
*[[Sepsis]](most common cause)
 
*Carcinoma
 
*Carcinoma
*Leukemia
+
*[[Leukemia]]
*Trauma
+
*[[Trauma]]
**Brain injury, crush injury, burns, [[rhabdo]], fat embolism
+
*[[Pancreatitis]]
*Liver disease
+
**Brain injury, [[crush injury]], [[burns]], [[rhabdomyolysis]], [[fat embolism]]
*Pregnancy
+
*[[hepatic failure|Liver disease]]
**Abruption, [[Amniotic Fluid Embolus]], septic abortion, HELLP syndrome
+
*[[Pregnancy]]-related
 +
**[[Placental Abruption]], [[Amniotic Fluid Embolus]], [[septic abortion]], [[HELLP Syndrome]], [[acute fatty liver of pregnancy]]
 
*[[Snake bite]]
 
*[[Snake bite]]
 
*[[ARDS]]
 
*[[ARDS]]
 
*[[Transfusion reaction]]
 
*[[Transfusion reaction]]
 +
*[[Transplant complications|Transplant rejection]]
  
 
==Clinical Features==
 
==Clinical Features==
''In given pt either bleeding or thrombosis will predominate (bleeding is more common ~65%)''
+
''[[hemorrhage|Bleeding]] or [[thromboembolism|thrombosis]] can predominate (bleeding is more common ~65%)''
*Shock (15%)
+
*[[Shoc]]k (15%)
 
*[[Acute renal failure]] (25-40%)
 
*[[Acute renal failure]] (25-40%)
*Hepatic dysfunction (19%)
+
*[[hepatic failure|Hepatic dysfunction]] (19%)
 
*Respiratory dysfunction (16%)
 
*Respiratory dysfunction (16%)
 
*[[Thromboembolism]] (7%)
 
*[[Thromboembolism]] (7%)
 
*CNS involvement (2%)
 
*CNS involvement (2%)
*Purpura fulminans (widespread arterial and venous thromboses)
+
*[[Purpura fulminans]] (widespread arterial and venous thromboses)
**Associated with significant bacteremia
+
**Associated with significant [[bacteremia]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
*Severe liver disease
 
**Also a/w prolonged PT/PTT, thrombocytopenia, incr D-dimer, incr FDPs
 
***However, D-dimer is usually only mildly elevated
 
 
 
{{Hemolytic anemia DDX}}
 
{{Hemolytic anemia DDX}}
 
 
{{Thrombocytopenia}}
 
{{Thrombocytopenia}}
 
 
{{Increased bleeding DDX}}
 
{{Increased bleeding DDX}}
 +
{{Bullous rashes DDX}}
  
==Diagnosis==
+
==Evaluation==
 
===Acute===
 
===Acute===
 
*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>
 
*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>
**Low (or dropping) in 98% of DIC pts
+
**[[thrombocytopenia|Low]] (or dropping) in 98% of DIC patients
 
**Sn, not Sp
 
**Sn, not Sp
 
**Repeat platelets may be necessary if first level normal or if need to trend
 
**Repeat platelets may be necessary if first level normal or if need to trend
 
*PT and PTT
 
*PT and PTT
**Prolonged
+
**[[coagulopathy|Prolonged]]
**May be normal in as many as 50% of DIC pts<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>
+
**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
 
**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>
 
**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
 
*Fibrinogen
 
**Low
 
**Low
**<100 correlates w/ severe DIC
+
**<100 correlates with severe DIC
**May be normal (acute phase reactant), up to 57% in  DIC pts<ref>Spero JA, Lewis JH, Hasiba U. Disseminated intravascular coagulation. Findings in 346 patients. Thromb Haemost. 1980 Feb 29. 43(1):28-33.</ref>
+
**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
 
*FDP
 
**Elevated
 
**Elevated
 
*[[D-dimer]]
 
*[[D-dimer]]
 
**Elevated
 
**Elevated
**Sn but not Sp: may also see in pts w/ chronic liver or renal disease
+
**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
 
**Combination of elevated FDP and d-dimer may increase sensitivity and specificity
 
*RBCs
 
*RBCs
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**Fragmented
 
**Fragmented
  
==Treatment==
+
==Management==
 
*Treat underlying illness
 
*Treat underlying illness
 
*Replacement treatment
 
*Replacement treatment
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****Consider repletion with [[cryoprecipitate]] to raise level to 100-150
 
****Consider repletion with [[cryoprecipitate]] to raise level to 100-150
 
***[[Platelets]]
 
***[[Platelets]]
****Consider repletion if <50K w/ bleeding or <20K without bleeding
+
****Consider repletion if <50K with bleeding or <20K without bleeding
 
***[[FFP]]
 
***[[FFP]]
 
****Consider repletion to goal of PT and PTT < 1.5 times the normal limit
 
****Consider repletion to goal of PT and PTT < 1.5 times the normal limit
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**[[Heparin]]
 
**[[Heparin]]
 
***Consider only if thromboembolic are predominant symptoms from chronic DIC
 
***Consider only if thromboembolic are predominant symptoms from chronic DIC
 +
 +
==Disposition==
 +
*Admit
  
 
==See Also==
 
==See Also==

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.