Difference between revisions of "Disseminated intravascular coagulation"

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==Background==
 
==Background==
#Widespread and inappropriate activation of the coagulation and fibrinolytic systems
+
*Widespread and inappropriate activation of the coagulation and fibrinolytic systems
##Exposure of blood to procoagulants such as tissue factor and cancer procoagulant
+
**Exposure of blood to procoagulants such as tissue factor and cancer procoagulant
##Formation of fibrin within the circulation
+
**Formation of fibrin within the circulation
##Fibrinolysis
+
**Fibrinolysis
##Depletion of clotting factors
+
**Depletion of clotting factors
##End-organ damage
+
**End-organ damage
#Chronic DIC occurs when hepatic/bone marrow production balances coag factor consumption
+
*Chronic DIC occurs when hepatic/bone marrow production balances coag factor consumption
  
 
==Causes==
 
==Causes==
#Infection
+
*Infection
##Most common cause of DIC
+
**Most common cause of DIC
##10%–20% of pts w/ Gram-neg sepsis have DIC
+
**10%–20% of pts w/ Gram-neg sepsis have DIC
###Septic pts more likely to have bleeding than thrombosis
+
***Septic pts more likely to have bleeding than thrombosis
##More likely to develop in asplenic pts or cirrhosis
+
**More likely to develop in asplenic pts or cirrhosis
#Carcinoma
+
*Carcinoma
##DIC is often chronic and compensated
+
**DIC is often chronic and compensated
##Thrombosis is more common than bleeding
+
**Thrombosis is more common than bleeding
#Leukemia
+
*Leukemia
##More likely to have bleeding than thrombosis
+
**More likely to have bleeding than thrombosis
#Trauma
+
*Trauma
##Brain injury, crush injury, burns, rhabdo, fat embolism
+
**Brain injury, crush injury, burns, rhabdo, fat embolism
#Liver disease
+
*Liver disease
##May have chronic compensated DIC; acute DIC may occur in setting of acute liver failure
+
**May have chronic compensated DIC; acute DIC may occur in setting of acute liver failure
#Pregnancy
+
*Pregnancy
##Abruption, [[Amniotic Fluid Embolus]], septic abortion, HELLP syndrome
+
**Abruption, [[Amniotic Fluid Embolus]], septic abortion, HELLP syndrome
#Envenomation
+
*Envenomation
##Rattlesnakes and other vipers
+
**Rattlesnakes and other vipers
##Bleeding not as serious as expected from lab values
+
**Bleeding not as serious as expected from lab values
#ARDS
+
*ARDS
##20% of pts with ARDS develop DIC; 20% of pts with DIC develop ARDS
+
**20% of pts with ARDS develop DIC; 20% of pts with DIC develop ARDS
#Transfusion reactions
+
*Transfusion reactions
  
 
==Clinical Features==
 
==Clinical Features==
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==Diagnosis==
 
==Diagnosis==
#Acute DIC
+
*Acute DIC
##Platlets
+
**Platlets
###Low (or dropping)
+
***Low (or dropping)
###Sn, not Sp
+
***Sn, not Sp
##PT
+
**PT
###Prolonged
+
***Prolonged
##Fibrinogen
+
**Fibrinogen
###Low
+
***Low
###<100 correlates w/ severe DIC
+
***<100 correlates w/ severe DIC
###May be normal (acute phase reactant)
+
***May be normal (acute phase reactant)
##PTT
+
**PTT
###Prolonged
+
***Prolonged
##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 pts w/ chronic liver or renal disease
##RBCs
+
**RBCs
###Fragmented (not specific)
+
***Fragmented (not specific)
#Chronic DIC
+
*Chronic DIC
##FDP: Elevated
+
**FDP: Elevated
##D-dimer: Elevated
+
**D-dimer: Elevated
##Platelet: Variable
+
**Platelet: Variable
##Fibrinogen: Normal-elevated
+
**Fibrinogen: Normal-elevated
##PT: Normal
+
**PT: Normal
##PTT: Normal
+
**PTT: Normal
##RBCs
+
**RBCs
###Fragmented
+
***Fragmented
  
 
==DDX==
 
==DDX==
#[[TTP]]-[[HUS]]
+
*[[TTP]]-[[HUS]]
##Pts usually have little or no prolongation of PT or PTT
+
**Pts usually have little or no prolongation of PT or PTT
#Severe liver disease
+
*Severe liver disease
##Also a/w prolonged PT/PTT, thrombocytopenia, incr D-dimer, incr FDPs
+
**Also a/w prolonged PT/PTT, thrombocytopenia, incr D-dimer, incr FDPs
###However, D-dimer is usually only mildly elevated
+
***However, D-dimer is usually only mildly elevated
#Heparin-induced thrombocytopenia
+
*Heparin-induced thrombocytopenia
  
 
{{Thrombocytopenia}}
 
{{Thrombocytopenia}}
  
 
==Treatment==
 
==Treatment==
#Treat underlying illness
+
*Treat underlying illness
#Replacement tx
+
*Replacement tx
##Only indicated in pts w/ documented DIC + bleeding or impending procedure
+
**Only indicated in pts w/ documented DIC + bleeding or impending procedure
###Fibrinogen
+
***Fibrinogen
####Consider repletion w/ cryoprecipitate to raise level to 100-150
+
****Consider repletion w/ cryoprecipitate to raise level to 100-150
###Platelets
+
***Platelets
####Consider repletion if <50K w/ bleeding or <20K without bleeding
+
****Consider repletion if <50K w/ bleeding or <20K without bleeding
###FFP
+
***FFP
###Vitamin K
+
***Vitamin K
###Folate
+
***Folate
##Heparin
+
**Heparin
###Consider only in pts w/ thromboembolic predominant symptoms from chronic DIC
+
***Consider only in pts w/ thromboembolic predominant symptoms from chronic DIC
  
 
==See Also==
 
==See Also==
 
*[[Coagulopathy (Main)]]
 
*[[Coagulopathy (Main)]]
  
==Source ==
+
==References==
Tintinalli
 
  
 
[[Category:Heme/Onc]]
 
[[Category:Heme/Onc]]

Revision as of 05:16, 6 June 2015

Background

  • 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

  • Infection
    • Most common cause of DIC
    • 10%–20% of pts w/ Gram-neg sepsis have DIC
      • Septic pts more likely to have bleeding than thrombosis
    • More likely to develop in asplenic pts or cirrhosis
  • Carcinoma
    • DIC is often chronic and compensated
    • Thrombosis is more common than bleeding
  • Leukemia
    • More likely to have bleeding than thrombosis
  • Trauma
    • Brain injury, crush injury, burns, rhabdo, fat embolism
  • Liver disease
    • May have chronic compensated DIC; acute DIC may occur in setting of acute liver failure
  • Pregnancy
  • 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

  • In given pt either bleeding or thrombosis will predominate
    • Bleeding is more common (65% of pts)
      • Ranges from petechiae/ecchymosis to life-threatening GI/CNS/pulm bleeding
      • Shock occurs in 15%
    • Renal failure (25-40%)
    • Hepatic dysfunction (19%)
    • Respiratory dysfunction (16%)
    • Thromboembolism (7%)
    • CNS involvement (2%)
    • Purpura fulminans (widespread arterial and venous thromboses)
      • Associated w/ significant bacteremia

Diagnosis

  • Acute DIC
    • Platlets
      • Low (or dropping)
      • Sn, not Sp
    • 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

  • TTP-HUS
    • Pts usually have little or no prolongation of PT or PTT
  • Severe liver disease
    • Also a/w prolonged PT/PTT, thrombocytopenia, incr D-dimer, incr FDPs
      • However, D-dimer is usually only mildly elevated
  • Heparin-induced thrombocytopenia

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

Treatment

  • Treat underlying illness
  • Replacement tx
    • Only indicated in pts w/ documented DIC + bleeding or impending procedure
      • Fibrinogen
        • Consider repletion w/ cryoprecipitate to raise level to 100-150
      • Platelets
        • Consider repletion if <50K w/ bleeding or <20K without bleeding
      • FFP
      • Vitamin K
      • Folate
    • Heparin
      • Consider only in pts w/ thromboembolic predominant symptoms from chronic DIC

See Also

References