Treatment

What are the major principles of disseminated intravascular coagulation (DIC) treatment?

a
Replenish clotting factors that have been consumed
Replacement therapies may be needed to correct coagulation abnormalities in patients who are bleeding or who are at high risk of bleeding.
b
Dampen activation of the clotting cascade
Inhibitory therapies (heparin and anticoagulant factor concentrates) may be used to modulate thrombin generation in certain patients with a thrombotic phenotype.
c
Promote increased platelet production in the bone marrow
d
Treat underlying disease causing DIC
Yes! A mainstay of treatment. In this case, the prompt administration of appropriate antibiotics is paramount.

To understand the challenge of treating disseminated intravascular coagulation (DIC), consider the following bonfire analogy. Assume you are camping in sub-zero temperatures at night and the heat from the fire you have built is your only way to survive the frigid temperature. There is more than enough wood around to keep the fire going. But there is catch: the black smoke arising from the fire is toxic and will lead to your demise if excessive. So, you must add just enough wood to maintain the fire without creating too much smoke.

In DIC, the clotting cascade is consumed, just as firewood is burned, and in doing so it creates fibrin, which occludes small vessels, just as the black smoke destroys the lungs. We are much better at detecting factor consumption (depletion of firewood) than we are the microvascular occlusion (the black smoke). An elevated PT, low fibrinogen, increased D-dimers/FDPs and decreased platelet count are all markers of consumption. So too is bleeding. In contrast, organ dysfunction, for example, skin necrosis, renal failure and cardiac ischemia may be subtle in its presentation and may have multiple causes. It may represent microvascular clot formation (though such thrombi are difficult to detect even at autopsy), or it may reflect other contributing factors, such as hypotension with secondary hypoperfusion or the effect of drugs. As a result, our natural tendency is to treat patients with DIC by replacing the missing factors, while ignoring the fibrin that is accumulating in the body. So, we are throwing fuel to the fire, when what we really need is a balance between replacement of factors and inhibition of thrombin generation and fibrin deposition.

A reminder of this patient’s hematological parameters at time of admission:

ParameterResult
Hemoglobin (Hb)10.6 g/dL
Platelets10 x 109/L
Prothrombin time (PT)18.4 seconds
Fibrinogen133 mg/dL

What would you like to recommend to the team taking care of the patient?

a
Cryoprecipitate to maintain fibrinogen > 100 mg/dL
b
Fresh frozen plasma to maintain PT < 14 seconds
c
Platelet transfusion to maintain platelet count > 50 x 10^9/L
d
None of the above unless the patient is bleeding or at high risk of bleeding
Replacement therapy should be reserved for patients who are actively bleeding, or who are high risk for bleeding, for example those with a platelet count < 10 x 109 and those undergoing surgery or invasive procedures.

Continual exposure to toxins adds fuel to the fire of chronic disease –  Pinnacle Naturopathy

Replacement therapies include:

  • Platelet transfusions
  • Fresh frozen plasma
  • Cryoprecipitate
  • Others:
    • Prothrombin complex concentrate
    • Fibrinogen concentrate 

Replacement therapies include:

ProductIndication
Platelet transfusionsRecommended in patients with active bleeding plus platelet count < 50 × 109/L, or high risk of bleeding owing to platelets < 20 × 109/L.
Fresh frozen plasma (FFP)Recommended in patients with active bleeding or requiring an invasive procedure and either prolonged PT/aPTT (> 1.5 × normal) or decreased fibrinogen (< 1.5 g/L).
Cryoprecipitate Recommended for patients with active bleeding plus severe hypofibrinogenemia (< 1.5 g/L) that persists despite FFP replacement.
Prothrombin complex concentrate (PCC)May be considered in actively bleeding patients if FFP transfusion is not possible.
Based on ISTH/SSC Harmonization of the Recommendations from the Three Guidelines. PT, prothrombin time; aPTT, activated partial thromboplastin time.

Inhibitory therapies include:

  • Therapeutic doses of heparin
  • Anticoagulant factor concentrates:
    • Activated protein C
    • Antithrombin
    • Recombinant thrombomodulin

Inhibitory therapies include:

ProductIndication
Heparin (therapeutic) May be considered in cases where thrombosis predominates; LMWH recommended over UFH.
AntithrombinNo formal recommendation due to lack of evidence of benefit, but may be considered.
Recombinant thrombomodulinNo formal recommendation due to lack of evidence of benefit, but may be considered.
Protein CHas been used in patients with purpura fulminans.
Based on ISTH/SSC Harmonization of the Recommendations from the Three Guidelines.

Let’s return to the patient. Here is an excerpt of the recommendations from the hematology consult service:

Course in hospital

The patient was admitted with septic shock and multiorgan failure (renal, pulmonary, cardiovascular, hematological). She was intubated in the emergency department, transferred to the intensive care unit where she received broad spectrum antibiotics (urine and blood cultures never grew any organisms) and continuous renal replacement therapy (CRRT). From a hematological standpoint, the recommendations from the hematology consult service were followed: the patient was not administered blood products, but was treated with intermediate doses of unfractionated heparin. Her coagulation assays normalized within 6 days. The patient was discharged home after a 4-week stay.