TRAINING and EDUCATION high D-dimer concentration ( 1.0 μg / mL ), and normal fibrinogen concentration ( 2.1 g / L ). Are these coagulation abnormalities due to liver failure – related coagulopathy or DIC secondary to an infection ?
Commentary : The differential diagnosis between the coagulopathy of liver disease and DIC is challenging , as many laboratory abnormalities point in the same direction . For example , more than 75 percent of patients with cirrhosis present with a platelet count of < 150 × 10 9 / L .
FIGURE Flowchart for the Diagnostic and Therapeutic Management of DIC
Clinical suspicion of DIC
• Underlying condition known to be associated with DIC
• Low / decreasing plateley count and / or prolonged global clotting assays ( PT , aPTT )
In most cases , the coagulopathy of liver disease can eventually be distinguished from the presence of DIC . In contrast to patients with DIC , those with severe liver disease have a stable low platelet count and only mildly elevated fibrin degradation products ( due to the simultaneous presence of fibrinolytic activation and impairment in liver failure ). In addition , clinical signs , such as the presence of splenomegaly and ascites , may indicate that liver disease , rather than DIC , is the cause of the coagulopathy . In the case presented , the DIC score was 4 ( suggestive of no DIC ) and , in combination with the clinical signs and symptoms , a diagnosis of coagulopathy due to severe liver failure was made .
Use DIC scoring algorithm
Scoring ≥5 : compatible with DIC
Score ‹ 5 : no DIC , consider repeating after 1-2 days
Case # 3 : Managing Complications of DIC
A 63-year-old man presented with severe cholangiosepsis due to an obstructive stone in the common bile duct . He was in shock , was respiratoryinsufficient , and developed acute renal failure . Coagulation analysis showed a low platelet count ( 48 × 10 9 / L ), prolonged PT ( 19 seconds ), prolonged aPTT ( 39 seconds ), a high D-dimer concentration ( 5.5 μg / mL ), normal fibrinogen concentration ( 2.8 g / L ), and an INR of 1.6 .
After the diagnosis of DIC was established , the patient was awaiting endoscopic retrograde cholangiopancreatography and restoration of bile-duct patency . He was treated with vasopressors , intubation , and mechanical ventilation , and antibiotics were started . What would be the most appropriate supportive treatment of the patient ’ s coagulopathy ?
Commentary : A proposed algorithm for the diagnostic and therapeutic management of DIC , based on whether a patient has active bleeding , overt thromboembolism , or neither clinical symptom , is presented in the FIGURE .
Available therapeutic interventions for DIC are mostly supportive and only partially effective , at best resulting in an amelioration of coagulation derangement or more rapid resolution of DIC . However , these approaches have not been proven to result in an improvement of clinically relevant outcomes , such as organ function or survival .
The cornerstone of supportive treatment of this coagulopathy , then , is proper management of the underlying condition ( i . e ., bile-duct drainage and antibiotics in the case detailed above ). If successfully undertaken , the coagulopathy will spontaneously resolve .
Therefore , in some situations , adjunctive supportive treatment aimed at the coagulation system will be required , because the coagulopathy may proceed even after adequate treatment of the underlying condition has been initiated .
Future Directions
Important questions about the proper management of this coagulopathy remain . For instance , a randomized controlled trial of heparin in patients with DIC is urgently needed because there is increasing circumstantial evidence that heparin may be beneficial in this setting .
Better supportive treatment of DIC also may stem from advances in early patient identification and risk stratification . Hypothetically , assays specifically aimed at the assessment of endothelial cell perturbation , in combination with early-stage systemic coagulopathy , would help identify high-risk patients to facilitate faster – and potentially more efficacious – interventions .
A better understanding of the influence of genomics in the host response leading to DIC will help determine a person ’ s risk of developing DIC and identify patients who are more susceptible to severe coagulopathy , with the eventual goal of tailoring treatment to the most vulnerable patients . ●
Active bleeding or need to undergo invasive procedure
• Platelet transfusion to keep platelet count › 30-50 × 10 9 / L
• Plasma and / or factor concentrate administration to keep PT ‹ 3 seconds , prolonged and keep fibrinogen › 1.5 g / L
• Vitamin K suppletioin in case of ( suspected ) vitimin K deficiency
• Antifibrinolytic treatment in case of excessive hyperfibrinolysis
Fast Facts
Treat underlying condition
No major bleeding or thrombosis
• Prophylactic ( LMW ) heparin
Overt thromoembolism and / or organ failure related to clot formation ( e . g . purpura fulminans )
• Therapeutic anticoagulant treatment ( e . g . unfractionated heparin )
• ( Restoration of natural anticoagulant pathways under evaluation in clinical studies )
✓✓Disseminated intravascular coagulation ( DIC ) is systemic activation of coagulation in its most extreme form and is characterized by organ failure and profuse bleeding from various sites .
✓✓DIC is not a disease in itself , but is always secondary to an underlying condition that causes the activation of coagulation , including sepsis , malignancy , and trauma .
✓✓There is no single laboratory test that can diagnose DIC , but reliable diagnosis can be made through a simple scoring algorithm based on routine hemostatic parameters .
✓✓The cornerstone of supportive treatment of DIC is management of the underlying condition . Therapeutic interventions to treat DIC are mostly supportive and only partially effective .
✓ ✓ Adjunctive supportive treatment aimed at the coagulation system ( i . e ., prothrombin complex or coagulation factor concentrates ) may be required even after adequate treatment of the underlying condition .
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