Difference between revisions of "Disseminated intravascular coagulation"

(Differential Diagnosis)
(Acute)
Line 45: Line 45:
 
==Diagnosis==
 
==Diagnosis==
 
===Acute===
 
===Acute===
*Platlets
+
*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)
+
**Low (or dropping) in 98% of DIC pts
 
**Sn, not Sp
 
**Sn, not Sp
*PT
+
**Repeat platelets may be necessary if first level normal or if need to trend
 +
*PT and PTT
 
**Prolonged
 
**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>
 +
**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
 
*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), 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>
*PTT
 
**Prolonged
 
 
*FDP
 
*FDP
 
**Elevated
 
**Elevated
Line 61: Line 63:
 
**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
 +
**Combination of elevated FDP and d-dimer may increase sensitivity and specificity
 
*RBCs
 
*RBCs
 
**Fragmented (not specific)
 
**Fragmented (not specific)

Revision as of 21:25, 20 February 2016

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

Clinical Features

In given pt either bleeding or thrombosis will predominate (bleeding is more common ~65%)

  • Shock (15%)
  • Acute renal failure (25-40%)
  • Hepatic dysfunction (19%)
  • Respiratory dysfunction (16%)
  • Thromboembolism (7%)
  • CNS involvement (2%)
  • Purpura fulminans (widespread arterial and venous thromboses)
    • Associated with significant bacteremia

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

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

Diagnosis

Acute

  • Platelets[1]
    • Low (or dropping) in 98% of DIC pts
    • 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 pts[2]
    • Serial coagulation testing may be necessary
    • PT, not INR, is used for monitoring[3]
  • Fibrinogen
    • Low
    • <100 correlates w/ severe DIC
    • May be normal (acute phase reactant), up to 57% in DIC pts[4]
  • FDP
    • Elevated
  • D-dimer
    • Elevated
    • Sn but not Sp: may also see in pts w/ 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

Treatment

  • Treat underlying illness
  • Replacement treatment
    • Only indicated in with documented DIC + bleeding or impending procedure
    • Heparin
      • Consider only if thromboembolic are predominant symptoms from chronic DIC

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.