Skip to Main Content

Key Features

Essentials of Diagnosis

  • A frequent cause of thrombocytopenia in hospitalized patients

  • Prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT)

  • Thrombocytopenia

  • Low/declining fibrinogen levels

General Considerations

  • Results from uncontrolled local or systemic activation of coagulation, which leads to depletion of coagulation factors and fibrinogen and often results in thrombocytopenia as platelets are activated and consumed

  • Numerous disorders are associated with DIC

    • Sepsis (in which coagulation is activated by presence of lipopolysaccharide)

    • Cancer

    • Trauma

    • Burns

    • Pregnancy-associated complications (in which tissue factor is released)

  • Aortic aneurysm and cavernous hemangiomas may promote localized intravascular coagulation

  • Snake bites may result in DIC due to the introduction of exogenous toxins

  • The HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is a severe form of DIC with a particularly high mortality rate that occurs in peripartum women

Clinical Findings

Symptoms and Signs

  • Bleeding usually occurs at multiple sites, such as intravenous catheters or incisions, and may be widespread (purpura fulminans)

  • Malignancy-related DIC may manifest principally as thrombosis (Trousseau syndrome)

Differential Diagnosis

  • Severe liver disease

  • Thrombotic thrombocytopenic purpura

  • Sepsis-induced thrombocytopenia or anemia

  • Heparin-induced thrombocytopenia

  • Other microangiopathic hemolytic anemia (eg, prosthetic valve hemolysis)

Diagnosis

Laboratory Tests

  • Thrombocytopenia

  • In early DIC

    • Platelet count and serum fibrinogen levels may initially remain within the normal range

    • Progressive thrombocytopenia (rarely severe)

    • Prolongation of PT

    • Decrease in fibrinogen levels

    • Elevation in aPTT

    • D-dimer levels typically elevated

    • Schistocytes on the blood smear in 10–20% of patients

  • In the HELLP syndrome

    • Elevated liver transaminases

    • Kidney injury due to gross hemoglobinuria and pigment nephropathy

  • Malignancy-related DIC may feature normal platelet counts and coagulation studies but a dropping platelet count and fibrinogen, with a rising INR, are often seen

Treatment

Medications

  • Underlying causative disorder must be treated (eg, antimicrobials, chemotherapy, surgery, or delivery of conceptus)

  • If clinically significant bleeding is present, hemostasis must be achieved; following is a strategy of managing DIC:

    • Assess for underlying cause of DIC and treat

    • Establish baseline platelet count, PT, aPTT, D-dimer, fibrinogen

    • Transfuse blood products only if ongoing bleeding or high risk of bleeding

      • Platelets: goal > 20,000/mcL (most patients) or > 50,000/mcL (severe bleeding, eg, intracranial hemorrhage)

      • Cryoprecipitate: goal fibrinogen level > 80–100 mg/dL

      • Fresh frozen plasma: goal PT and aPTT < 1.5 × normal

      • Packed red blood cells: goal hemoglobin > 8 g/dL or improvement in symptomatic anemia

    • Follow platelets, aPTT/PT, fibrinogen every 4–6 hours or as clinically indicated

    • Heparin (initial infusion, 5–10 units/kg/h)

      • May be considered when bleeding is persistent

      • Do not administer bolus

      • Contraindicated if platelets cannot be maintained at > 50,000/mcL, in cases of gastrointestinal or central nervous system (CNS) bleeding, in conditions that may require surgical management, or placental abruption

    • Follow laboratory parameters every 4–6 hours until ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.