How should I treat DIC?

Let’s review: DIC is a condition that often develops under extreme physiologic stress, such as sepsis, malignancy, surgery/trauma, pregnancy, burns, or snake bites, even. Clotting factors get stuck together and form micro-thrombi which leads to two ironic pathways:

  • Tissue factor activation, thrombin activation, which causes clotting
  • Because the clotting factors are used up and FDP’s are released, oozing is also a problem
Showing the possible subtypes of DIC. from: http://download.springer.com/static/pdf/933/art%253A10.1186%252F2052-0492-2-15.pdf?originUrl=http%3A%2F%2Fjintensivecare.biomedcentral.com%2Farticle%2F10.1186%2F2052-0492-2-15&token2=exp=1447260188~acl=%2Fstatic%2Fpdf%2F933%2Fart%25253A10.1186%25252F2052-0492-2-15.pdf*~hmac=d9286a14b5432b78149e2a1d554a6bbe22e24dbd94aa5acbe80e2c6758c211c8
Showing the possible subtypes of DIC. from: Wada et al 2014, Journal of Intensive Care. 

The #1 way to treat DIC: treat the underlying cause!

The treatments for DIC are divided into blood products for coagulation, and anticoagulation.

BLOOD PRODUCTS

Vitamin K: often first-line therapy, can be given orally or IV. While factor VII may increase within 4 hours, the more important increase in factor II takes at least 24 hours (and the PO form takes even longer than that).

Fresh frozen plasma: FFP contains factors II, VII, IX, X, XIII (all vitamin-K dependent), as well as prothrombin complex concentrates. However, it has significant potential side effects, including volume overload and TRALI.

Prothrombin complex concentrate: PCC contains either three (II, IX, X) or four (II, VII, IX, X) clotting factors, along with C and S. It is faster-acting than FFP and has a better safety profile with less risk of overload, TRALI because of the cleansing process, and no increased risk of thrombotic events.

For DIC: Vitamin K is often given, although FFP should be added on at a rate of 15 ml/kg. Because of the risk of transfusing too much volume, small amounts of PCC can be added on. DIC is characterized by low fibrinogen and so replacement with pure fibrinogen or cryoprecipitate may be helpful.

ANTICOAGULATION

All patients with DIC should receive at least prophylactic doses of heparin. LWMH has better evidence than UFH. If a patient has thrombosis-type DIC, therapeutic doses of heparin should be considered. There’s no evidence right now showing that other anticoagulants like fondaparinux are more effective.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s