Coach’s Corner

About Coach’s Corner

In the best of all worlds, clinical practice guidelines provide recommendations about diagnosis and treatment that are based on solid evidence from phase 3 clinical trials. In many cases, such evidence does not exist and recommendations are provided based on expert opinion. Even then, many questions pertinent to clinical care may be left out of guidelines. In Coach’s Corner, we aim to address some of these gaps by surveying the opinion of clinical experts from the TBP board of advisors in areas where there exists a gray zone. This exercise is not meant to provide definitive guidance for patient care, but rather is designed to highlight the importance of clinical experience and critical thinking in the decision making process.

The opinions presented in this case were obtained in May 2022, and may be subject to change as new evidence emerges.

Question 1

Background: Clinical practice guidelines recommend using a scoring system rather than clinical gestalt for diagnosing disseminated intravascular coagulation (DIC).

Question: Do you routinely use a clinical scoring system for diagnosing DIC, and if not, why?

Question 2

Background: The clinical scoring systems include parameters that are altered at baseline in chronic liver disease. 

We asked our experts: 

Question: How do you make a diagnosis of DIC in a patient with cirrhosis? How helpful are FVIII levels in differentiating between the 2 conditions?

Question 3

Background: Clinical practice guidelines recommend replacement therapies (platelets, fresh frozen plasma [FFP], cryoprecipitate) only if the patient is bleeding or is at increased risk of bleeding (for example, undergoing an invasive procedure). Yet it is not unusual to see replacement therapies targeted towards numbers (PT, fibrinogen and platelet count) regardless of the bleeding status/risk of the patient. 

We asked our experts:

Question: Under what conditions do you recommend replacement therapies in DIC?

 

Question 4

Background: Harmonization of the recommendations from three guidelines on DIC state the following: “Therapeutic doses of heparin should be considered in cases of DIC where thrombosis predominates (low quality). The use of low molecular weight heparin (LMWH) is preferred to the use of unfractionated heparin (UFH) in these cases (low quality).” Yet heparin therapy is not widely used for DIC, at least in the United States. 

Question: Under what conditions do you recommend the use of therapeutic doses of heparin in DIC, and what dose do you actually use?