Disseminated Intravascular Coagulation

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Disseminated Intravascular Coagulation
 
A patient is brought into the ED in cardiac arrest. After ROSC, you notice large amounts of bright red blood from both the rectum and mouth. As part of your resuscitation, you place multiple central venous catheters for access and blood pressure monitoring. After placement, you notice the insertion sites persistently oozing. 
Your labs are significant for a hemoglobin of 6.7, platelets of 47k, and prolonged PT/INR.
What hematologic emergency is your patient suffering from and what are your treatment options?
 
This patient is suffering from Disseminated Intravascular Coagulation(DIC) While there are formally two types of DIC, acute and chronic, we will be focusing on acute DIC.
DIC is a massive, bodywide activation of the coagulation cascade causing both extreme coagulation and fibrinolysis in an uncontrolled, unregulated fashion. A consumptive coagulopathy, DIC rapidly lowers the levels of coagulation factors and platelets as the coagulation cascade is activated. Decreased blood flow and thrombi can result from the active coagulation and result in end-organ damage. Fibrinolysis products can interfere with the coagulation process, further increasing bleeding risk. As a result of rapid consumption of coagulation factors, patients will present with elevated PT/INR and PTT(although not necessary for diagnosis), decreased platelets, and anemia as a result of frank bleeding and intravascular hemolysis. Fibrinogen, as a precursor to fibrin clots, will also be low. D-Dimer levels will be elevated reflecting the large amount of clot burden and fibrinolysis throughout the body. 
 
It is important to realize that DIC is a rare diagnosis. However, when present, it is usually triggered by underlying infection, malignancy, trauma, or obstetric causes. While these are the large contributors to DIC, many other reasons can cause it as well such as liver disease and toxidromes. 
 
The International Society on Thrombosis and Hemostasis have developed a 5 step scoring system for the risk of DIC with a 91% sensitivity and 97% specificity rate. 
 
Here are your mainstay treatment options:
  1. Treat the underlying cause - easier said than done 
  2. Packed Red Blood Cells - As needed for anemia from the bleeding 
  3. Platelets - No clear consensus; platelets often will not be critically low in patients with DIC. Transfuse if Platelets <10k, consider if <50k and active bleeding 
  4. Fresh Frozen Plasma - As needed for elevations in PT and PTT. FFP, along with PRBC, will be the main two products given in DIC
  5. Cryoprecipitate - Again, no clear consensus on when to use versus FFP, but consider with active hemorrhaging and fibrinogen levels <100. Can use with FFP in more severe cases. 
 
References
Venugopal A. Disseminated intravascular coagulation. Indian J Anaesth. 2014;58(5):603-608. doi:10.4103/0019-5049.144666
Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009 Apr;145(1):24-33. doi: 10.1111/j.1365-2141.2009.07600.x. Epub 2009 Feb 12. PMID: 19222477.
Squizzato A, Hunt BJ, Kinasewitz GT, Wada H, Ten Cate H, Thachil J, Levi M, Vicente V, D'Angelo A, Di Nisio M. Supportive management strategies for disseminated intravascular coagulation. An international consensus. Thromb Haemost. 2016 May 2;115(5):896-904. doi: 10.1160/TH15-09-0740. Epub 2015 Dec 17. PMID: 26676927.