inpatient / hematology and oncology

Disseminated Intravascular Coagulopathy (DIC)

Last Updated: 1/4/2023

# Disseminated Intravascular Coagulopathy (DIC)

-- History: ***
-- Clinical: *** clotting, bleeding (purpura, petechiae), organ failure
-- Exam: ***
-- Data: *** PT/PTT, D-Dimer, Fibrinogen, plts, schistocytes (smear), LDH, haptoglobin
-- Etiology/DDx: *** spesis, cancer, trauama, ARDS, pancreatitis

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- Trend CBC, coags, D-Dimer, Fibrinogen q6-8 hours

-- Treat underlying cause
-- Transfuse plts <10 (<50 if bleeding), cryo if fibrinogen <100, FFP if INR >2
-- supplement vitamin K if there is a suspected deficiency

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If You Remember Nothing Else

DIC is a life-threatening and complex phenomenon caused by the imbalance of clot formation and breakdown. It is often caused by sepsis, cancer, or trauma. Treatment involves addressing the underlying cause and transfusing to replenish clotting factors and platelets to prevent hemorrhage.

Clinical Pearls

  • Systemic formation of microthrombi through platelet and fibrinogen consumption which in turn can lead to bleeding due to lack of clotting factors
  • Decompensated DIC shows thrombocytopenia, prolonged PT/PTT/INR, decreased fibrinogen, and elevated D-dimer level
  • Acute DIC usually has a trigger such as sepsis or trauma and starts as a hypercoagulable state
  • Acute DIC from leukemia tends to cause the hyperfibrinolytic form of DIC which leads to oozing
  • Chronic DIC is often due to metastatic adenocarcinomas and causes a gradual decrease in coagulation factors which the body can compensate for
  • Microvascular thrombosis can cause organ failure including renal failure (most common), ARDS, delirium/coma, adrenal filure, and purpura fulminans (gangrene); Macrovascular thrombosis causes DVTs and PE
  • Thrombocytopenia is often the earliest and most sensitive indication of DIC
  • Fibrinogen is only low in ~25% of patients with DIC; Sepsis increases fibrinogen, so may be elevated or normal

Trials and Literature

  • DIC Review - "The pathophysiology of DIC, in simple terms, is that the underlying disease stimulates such a strong procoagulant activity that it results in an excess of thrombin, which then overcomes the anticoagulant control mechanisms of protein C (PrC), antithrombin (AT), and the tissue factor pathway inhibitor (TFPI), allowing thrombosis to freely take place throughout the vasculature." (Am J Clin Pathol, 2016)
  • Bleeding and Coagulopathies in Critical Care (NEJM, 2014)

Other Resources