Disseminated intravascular coagulation: Difference between revisions
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− | == |
+ | ==Background== |
− | * |
+ | *Systemic microvascular coagulation leading to organ dysfunction and depletion of clotting factors and platelets |
+ | |||
+ | ===Etiologies=== |
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+ | |||
+ | *[[Sepsis]], from gram-negative bacteria, gram-positive bacteria, some viruses, and some parasites (including [[malaria]]) |
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+ | *Trauma, particularly brain trauma |
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+ | **Solid tumour, especially mucinous tumours (pancreatic, gastric, ovarian) and brain tumours |
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+ | **[[Leukemia|Leukaemia]], especially [[promyelocytic leukemia]] |
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+ | *Obstetric complications |
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+ | **[[Acute fatty liver of pregnancy]] |
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+ | **Recreational drug use |
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== Differential Diagnosis == |
== Differential Diagnosis == |
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+ | * [[Thrombotic microangiopathy|Thrombotic microangiopathies]], including [[TTP]] and [[HUS]] |
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− | * Sepsis and severe infection |
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+ | * Severe [[liver failure]] |
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− | * Trauma |
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+ | * [[Heparin-induced thrombocytopenia]] |
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+ | * Catastrophic [[antiphospholipid syndrome]] |
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− | ** Solid tumours |
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− | ** Leukaemia |
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− | * Obstetric |
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− | ** Recreational drugs |
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− | == |
+ | ==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) |
+ | {| class="wikitable" |
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− | {| |
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− | ! |
+ | !Marker |
− | ! |
+ | !Value |
− | ! |
+ | !Score |
|- |
|- |
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− | | |
+ | |Platelet count |
− | | |
+ | |>100<br /><100<br /><50 |
− | | |
+ | |0<br />1<br />2 |
|- |
|- |
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− | | |
+ | |Elevated fibring marker (e.g. D-dimer, fibrin degradation products) |
− | | |
+ | |no increase<br />moderate increase<br />strong increase |
− | | |
+ | |0<br />2<br />3 |
|- |
|- |
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− | | |
+ | |Prolonged PT |
− | | |
+ | |<3 sec<br />>3 sec<br />>6 sec |
− | | |
+ | |0<br />1<br />2 |
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|- |
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+ | |Fibrinogen level |
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+ | |>1 g/L<br /><1 g/L |
− | | |
+ | |0<br />1 |
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|} |
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− | === |
+ | ===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:Hematology]] |
Latest revision as of 23:05, 16 September 2022
Background
- Systemic microvascular coagulation leading to organ dysfunction and depletion of clotting factors and platelets
Etiologies
- Sepsis, from gram-negative bacteria, gram-positive bacteria, some viruses, and some parasites (including malaria)
- Trauma, particularly brain trauma
- Organ destruction e.g pancreatitis
- Malignancy
- Solid tumour, especially mucinous tumours (pancreatic, gastric, ovarian) and brain tumours
- Leukaemia, especially promyelocytic leukemia
- Obstetric complications
- Vascular abnormalities
- Large haemangiomata
- Vascular aneurysm
- Severe liver failure
- Toxic and immunological insults
- Snake bite
- Recreational drug use
- Acute hemolytic transfusion reaction from ABO incompatibility
- Transplant rejection
Differential Diagnosis
- Thrombotic microangiopathies, including TTP and HUS
- Severe liver failure
- Heparin-induced thrombocytopenia
- Catastrophic antiphospholipid syndrome
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. Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines. J Thromb Haemost. 2013;11:761–767.