Disseminated Intravascular Coagulation/DIC

DIC is a type of Microangiopathic Haemolytic Anaemia where inappropriate activation of coagulation pathways and subsequent fibrin deposition in small vessels results in thrombus formation and a depletion of platelets and clotting factors. Generalised bleeding in 3+ unrelated sites is highly suggestive of DIC.

It's risk factors include Major trauma or burns, Multiple-organ failure, Severe sepsis, Severe obstetric complications, Haematological malignancies.

Pathophysiology

The immune cells involved here release lots of cytokines, which cause blood vessels to become more permeable, leading to oedema, therefore reducing how much oxygen can reach tissues.

When the coagulation system is activated, it leads to fibrin deposition in vessels, further affecting tissue perfusion. There's a huge consumption of platelets and clotting factors as they’re being used up to form the clots, therefore leading to thrombocytopenia, haemorrhages, and an inability to form new clots and stop bleeding.

N.B. Patients go through a phase of widespread clotting, following by haemorrhaging as the platelets and CFs are used up. DIC is usually fatal.

Presentation

• Epistaxis

• Gingival bleeding

• Haematuria

• Bleeding from cannula sites

• O/E - Petechiae, Ecchymosis (Bruising), Confusion, Hypotension, Hypoxia

Investigations

• Platelets – Decreased (Thrombocytopenia)

• Fibrinogen – Decreased

• D-dimer – Raised

• INR – Raised

The diagnosis is based on the presence of 1+ known underlying cause of DIC + 1 abnormal coagulation test e.g. Low platelets, Raised INR, Raised D-dimer, Low fibrinogen.

Management

Low bleeding risk patients - Treat the underlying disorder

High bleeding risk or actively bleeding patients - Treat the underlying disorder and give platelets, coagulation factors and inhibitors

• Platelets if < 20 with active bleeding

• FFP for replacement of coagulation factors and inhibitors when significant bleeding or fibrinogen < 100