Disseminated intravascular coagulation - Revision history

Aidan at 03:05, 17 September 2022

2022-09-17T03:05:33Z

← Older revision		Revision as of 03:05, 17 September 2022
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	===Etiologies===		===Etiologies===

			*[[Sepsis]], from gram-negative bacteria, gram-positive bacteria, some viruses, and some parasites (including [[malaria]])
	*[[Sepsis]] and severe infection
	*Trauma		*Trauma, particularly brain trauma
	*Organ destruction e.g [[pancreatitis]]		*Organ destruction e.g [[pancreatitis]]
	*[[Malignancy]]		*[[Malignancy]]
			**Solid tumour, especially mucinous tumours (pancreatic, gastric, ovarian) and brain tumours
	**Solid tumour
	**[[Leukemia\|Leukaemia]]		**[[Leukemia\|Leukaemia]], especially [[promyelocytic leukemia]]
	*Obstetric		*Obstetric complications
	**[[Amniotic fluid embolism]]		**[[Amniotic fluid embolism]]
	**[[Placental abruption]]		**[[Placental abruption]]
	**[[Preeclampsia\|Pre-eclampsia]]		**[[Preeclampsia\|Pre-eclampsia]]
			**[[Acute fatty liver of pregnancy]]
	*Vascular abnormalities		*Vascular abnormalities
	**[[Hemangioma\|Large haemangiomata]]		**[[Hemangioma\|Large haemangiomata]]
Line 22:		Line 23:
	**[[Snake bite]]		**[[Snake bite]]
	**Recreational drug use		**Recreational drug use
	**~~ABO~~ transfusion incompatibility		**[[Acute hemolytic transfusion reaction]] from ABO incompatibility
	**Transplant rejection		**Transplant rejection

			== Differential Diagnosis ==

			* [[Thrombotic microangiopathy\|Thrombotic microangiopathies]], including [[TTP]] and [[HUS]]
			* Severe [[liver failure]]
			* [[Heparin-induced thrombocytopenia]]
			* Catastrophic [[antiphospholipid syndrome]]

	==Investigations==		==Investigations==

Aidan at 13:54, 16 September 2022

2022-09-16T13:54:12Z

← Older revision		Revision as of 13:54, 16 September 2022
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	*Organ destruction e.g [[pancreatitis]]		*Organ destruction e.g [[pancreatitis]]
	*[[Malignancy]]		*[[Malignancy]]
	**Solid ~~tumours~~		**Solid tumour
	**Leukaemia		**[[Leukemia\|Leukaemia]]
	*Obstetric		*Obstetric
	**Amniotic fluid embolism		**[[Amniotic fluid embolism]]
	**Placental abruption		**[[Placental abruption]]
	**Pre-eclampsia		**[[Preeclampsia\|Pre-eclampsia]]
	*Vascular abnormalities		*Vascular abnormalities
	**Large haemangiomata		**[[Hemangioma\|Large haemangiomata]]
	**Vascular aneurysm		**Vascular aneurysm
	*Severe liver failure		*Severe [[liver failure]]
	*Toxic and immunological insults		*Toxic and immunological insults
	**Snake ~~bites~~		**[[Snake bite]]
	**Recreational ~~drugs~~		**Recreational drug use
	**ABO transfusion incompatibility		**ABO transfusion incompatibility
	**Transplant rejection		**Transplant rejection

Aidan at 17:03, 21 April 2021

2021-04-21T17:03:17Z

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Maintenance script: Imported from text file

2020-07-04T01:17:32Z

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== Definition ==

* Systemic microvascular coagulation leading to organ dysfunction and depletion of clotting factors and platelets

== Differential Diagnosis ==

* Sepsis and severe infection
* Trauma
* Organ destruction e.g pancreatitis
* Malignancy
** Solid tumours
** Leukaemia
* Obstetric
** Amniotic fluid embolism
** Placental abruption
** Pre-eclampsia
* Vascular abnormalities
** Large haemangiomata
** Vascular aneurysm
* Severe liver failure
* Toxic and immunological insults
** Snake bites
** Recreational drugs
** ABO transfusion incompatibility
** Transplant rejection

== Investigations ==

* Thrombocytopenia is the most sensitive (Sn 98%)
* D-dimer also sensitive, but not specific
* Elevated INR/PTT (Sn 50-60%), but can be normal
* Low fibrinogen is not very sensitive (Sn 28%), but serial measurement may be helpful
* Blood film may show fragments

== ISTH Diagnostic Scoring System ==

* Only useful in the context of an underlying disorder known to be associated with overt DIC
* Needs PT, platelet count, fibrinogen, and fibrin-related marker (e.g. D-dimer)

{|
! Marker
! Value
! Score
|-
| Platelet count
| >100 <100 <50
| 0 1 2
|-
| Elevated fibring marker (e.g. D-dimer, fibrin degradation products)
| no increase moderate increase strong increase
| 0 2 3
|-
| Prolonged PT
| <3 sec >3 sec >6 sec
| 0 1 2
|-
| Fibrinogen level
| >1 g/L <1 g/L
| 0 1
|}

=== Interpretation ===

* ≥5 compatible with over DIC: repeat score daily
* <5 suggestive for non-overt DIC: repeat in next 1-2 days

== Management ==

* '''Treat the underlying cause!'''

=== Transfusions ===

* Only supplement blood products if they are actively bleeding, or to prepare them for an invasive procedure that may cause bleeding

==== Platelets ====

* Platelets to target ≥50 if bleeding
* Platelets not needed if not bleeding unless otherwise at risk
** Weak evidence to target 10-20

==== Plasma and components ====

* May be indicated in bleeding patients with PT or aPTT >1.5x normal or fibrinogen <1.5 g/L
* FFP 15-30 ml/kg can correct the coagulopathy
* PCC lacks Factor V and may worsen coagulopathy due to trace amounts of active factors
* Fibrinogen 3 g should raise the plasma fibrinogen by about 1 g/L
** Can be given as 4 units FFP, 2 units pooled cryoprecipitate, or 3 g fibrinogen concentrate

=== Anticoagulation ===

* In cases of severe thrombosis, including arterial or venous thromboembolism, severe purpura fulminans associated with acral ischemia or vascular skin infarction, consider unfractionated heparin (UFH)
** Target a PTT 1.5-2.5x normal
** Monitor closely for bleeding
* Other patients still need DVT prophylaxis with heparin or LMWH

== Further Reading ==

# Wada H ''et al.'' [https://doi.org/10.1111/jth.12155 Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines]. ''J Thromb Haemost''. 2013;11:761–767.

[[Category:Hematology]]
[[Category:Critical care]]