The first step is to treat the underlying diagnosis. Supportive care for DIC includes infusion of fresh-frozen plasma 10 mL/kg, platelet and blood transfusion,7 and cryoprecipitate in order to improve abnormal coagulation and reduce active bleeding (Figure 45-1). Therapy is indicated in patients who are actively bleeding or who are at high risk of bleeding, but should not be used merely to "treat" abnormal laboratory values.
Algorithm for disseminated intravascular coagulation (DIC). CNS, central nervous system; DIC, disseminated intravascular coagulation; DVT, deep venous thrombosis; GI, gastrointestinal; PRBCs, packed red blood cells.
Heparin has been used in patients with thrombotic manifestations of DIC based on anecdotal evidence. Experimental studies have shown that heparin can at least partly inhibit the activation of coagulation in DIC.8 There are no randomized controlled trials to demonstrate the use of heparin in patients with DIC leading to any improvement in clinical outcomes. Small uncontrolled studies have reported limited benefits with heparin use and have demonstrated that heparin infusion may improve laboratory abnormalities associated with DIC.9,10,11 If it is used, a bolus is usually not needed and it should be initiated at 500 units/h as a starting dose. Patients must be monitored carefully for any bleeding.
Given the association of abnormal coagulation with systemic inflammation, substitution of coagulation products such as antithrombin III and protein C has been attempted in the setting of sepsis and DIC. However, results have been conflicting. The largest study using antithrombin III in patients with DIC demonstrated no benefit. Activated protein C has been shown in some studies to have a possible mortality benefit in patients with severe sepsis.12,13,14,15
The overall prognosis of acute DIC is poor, with reported mortality rates ranging from 40% to 80% in patients with severe sepsis, trauma, or burn injuries.16,17,18 Mortality is thought to be affected by the magnitude of underlying disease processes causing the DIC, rather than DIC per se. However, in a recent study of traumatic brain injury, patients with higher DIC scores were found to have increased likelihood of death or persistent vegetative state compared to patients with lower DIC scores, irrespective of their Glasgow Coma Scale scores.19 In any event, early and prompt treatment of the underlying disease and providing hemodynamic support are the mainstays of DIC management.
! Critical Considerations
DIC is a clinical syndrome with an underlying etiology, not a diagnosis.
The diagnosis of DIC is clinical, with laboratory values that may support your clinical suspicion.
DIC is associated with a poor prognosis.
DIC can present with thrombotic or hemorrhagic complications, or both simultaneously.
First-line treatment of DIC is to treat the underlying diagnosis.
Supportive care includes fresh-frozen plasma and blood and platelet transfusions.
Consider low-dose heparin in patients with thrombotic manifestations, with close clinical monitoring for signs of bleeding.