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Disseminated Intravascular Coagulation
Haemostasis
COAGULATION FIBRINOLYSIS
DIC
• an acquired syndrome
• intravascular activation of coagulation leading to consumptive coagulopathy
• causing damage to the microvasculature and organ dysfunction
(International Society of Thrombosis and Hemostasis [ISTH]).
DIC
• A dynamic condition triggered by variety of stimuli
• Require serial testing and clinical assessment
• No formula/ specific regimes
• Therapy must be individualized, tailored to patient specific needs
Clinical assessment
• Identify the underlying cause
• Identify possible DIC– Bleeding from more than one site
– Uncontrolled bleeding from puncture sites
– Thrombosis and Multi Organ Dysfunction
• Clinical picture ranges from major haemorrhage with or without thrombosis to a clinically stable state that can only be detected by laboratory testing.
Identify the underlying cause
Identify the underlying cause
Laboratory investigations
No single test that can establish or rule out DIC.
Dynamic situation and a single test reflects only at that time point.
• Coagulation profile
• PT and aPTT– Shows the degree of
coagulation factor consumption & activation
– Early can be shortened, normal
– Late -prolonged
• Fibrinogen- low < 1g/l– Acute phase protein ( falsely
normal)
• Fibrin Degradation Products
• D-Dimers– Shows the extent of fibrin
formation
• Thombin time
• FBP- Microangiopathic Haemolytic Anemia (MAHA)
• Plt- thrombocytopenia
Management of DIC
TREAT THE UNDERLYING CAUSE
Management of DIC
• Stabilize haemodynamically (ABC), correct acidosis
• Manage clinically with the assistance of laboratory support
• Judicious blood products if bleeding
• Consider heparin/ LMWH
• ?Role of antifibrinolytic agents (tranexamic acid) in special situations
Blood products
Role of blood products• Judicious use of blood products in bleeding
situations
• Don’t just treat the lab results!
• Needs correlation with clinical findings.
• May worsen the thrombotic manifestations of DIC
Role of blood products in treatment of DIC
• RBCs
• Platelets
• FFP
• Cryoprecipitate
• Keep hemoglobin in range of 8 to 10 g/dL
• Depends on risks for bleeding, not just the platelet count. >50,000/μL
• Enormously overrated in treatment of DIC, especially since recent evolution of our understanding and danger of TRALI. Some indication to supplement RBC transfusions in “total body exchange” situations
• Probably best source of fibrinogen. Reasonable target is to keep fibrinogen levels between 50 and 100 mg/dL
‘DIC regime’
6 units of cryoprecipitate
+ 4 units of platelets
+ 2 units of FFP
‘DIC regime’
6 units of cryoprecipitate
+ 4 units of platelets
+ 2 units of FFP
Pitfalls in DIC regime
• One size fits all ? 40 kg vs 80kg pt
• More concern about preventing coagulopathy than replacing blood loss
• Forget to transfuse PRBC!
• On receipt of DIC regime, transfusing platelets, FFP, Cryoprecipitate and lastly PRBC which is the one most needed
• Request DIC regime early without sending a DIC screen
Thank you