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Disseminated intravascular coagulation

Specialties > Child health

Background knowledge 🧠

Definition

  • Disseminated intravascular coagulation (DIC) is a complex acquired disorder characterised by widespread activation of the coagulation cascade.
  • Results in the formation of microthrombi throughout the microvasculature.
  • Leads to simultaneous thrombosis and bleeding due to the consumption of platelets and coagulation factors.

Epidemiology

  • Incidence varies with underlying cause; more common in severe infections, trauma, and malignancies.
  • Higher incidence in critically ill patients.
  • Associated with high mortality, especially if not promptly diagnosed and treated.
  • May occur at any age but more frequent in adults.

Aetiology and Pathophysiology

  • Triggered by conditions that activate the coagulation cascade, such as sepsis, trauma, malignancies, obstetric complications (e.g., placental abruption), and severe transfusion reactions.
  • Release of procoagulant substances (e.g., tissue factor) into the circulation leads to systemic activation of clotting.
  • Microthrombi formation in small vessels causes ischaemia and organ dysfunction.
  • Consumption of clotting factors and platelets leads to bleeding.
  • Fibrinolysis is activated but becomes overwhelmed, contributing to both thrombosis and bleeding.

Types

  • Acute DIC: Rapid onset, often associated with severe illness, leading to quick consumption of coagulation factors and platelets.
  • Chronic DIC: Slower onset, often seen in malignancy, with ongoing coagulation and fibrinolysis.
  • Compensated DIC: Subclinical, where the body compensates for the coagulation process without clinical bleeding or thrombosis.

Clinical Features 🌡️

Symptoms

  • Non-specific symptoms including malaise and fever.
  • Bleeding tendencies, such as easy bruising, haematuria, or gastrointestinal bleeding.
  • Symptoms related to underlying cause, e.g., sepsis or malignancy.
  • Dyspnoea if pulmonary involvement.
  • Chest pain or ischemic symptoms if coronary or peripheral vessels are involved.

Signs

  • Petechiae and purpura on the skin.
  • Oozing from venepuncture sites or wounds.
  • Haemorrhagic bullae or extensive bruising.
  • Signs of thrombosis, such as deep vein thrombosis or arterial occlusion.
  • Organ dysfunction, including renal impairment or hepatic dysfunction.
  • Hypotension and shock in severe cases.

Investigations 🧪

Tests

  • Full blood count: Thrombocytopenia is common.
  • Coagulation screen: Prolonged PT, aPTT, and reduced fibrinogen.
  • D-dimer: Elevated, reflecting increased fibrinolysis.
  • Blood film: Schistocytes may be present.
  • Liver function tests: May be deranged if hepatic involvement.
  • Renal function tests: Elevated creatinine if renal impairment.
  • Arterial blood gases: May show metabolic acidosis in severe cases.

Management 🥼

Management

  • Treat underlying cause (e.g., antibiotics for sepsis, surgery for obstetric causes).
  • Supportive care: IV fluids, oxygen therapy, and haemodynamic support as needed.
  • Blood products: Fresh frozen plasma, platelets, and cryoprecipitate to replenish clotting factors and platelets.
  • Anticoagulation: Heparin may be used in cases with predominant thrombosis, but with caution.
  • Monitoring: Regularly monitor coagulation profile, platelet count, and organ function.

Complications

  • Severe bleeding leading to haemorrhagic shock.
  • Multiple organ failure due to microvascular thrombosis.
  • Increased risk of venous thromboembolism.
  • Death if not rapidly and effectively managed.

Prognosis

  • Varies widely depending on underlying cause and promptness of treatment.
  • High mortality rate in acute DIC, particularly if associated with sepsis or major trauma.
  • Chronic DIC has a better prognosis but still requires careful management.
  • Early identification and treatment of the underlying cause are crucial for improving outcomes.

Key Points

  • DIC is a life-threatening condition requiring prompt diagnosis and treatment.
  • Always consider underlying causes such as sepsis, trauma, or malignancy.
  • Management focuses on treating the underlying cause, supporting organ function, and correcting coagulation abnormalities.
  • Regular monitoring and multidisciplinary care are essential for improving patient outcomes.

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