Disseminated Intravascular Coagulopathy (DIC)

Sample for Disseminated Intravascular Coagulopathy (DIC)

1. Collect the blood for PT and PTT.
   1. Blood samples were collected in sodium citrate as an anticoagulant.
2. Immediately do an assay for clotting factors ( coagulation profiles).
3. Perform the bleeding time.
4. Collect blood for a complete blood examination, particularly for the platelet count.

Purpose of the test (Indications) for Disseminated Intravascular Coagulopathy (DIC)

1. To exclude septicemia.
2. Amniotic fluid embolism.
3. Retention of the dead fetus.
4. Malignant neoplasia.
5. In liver cirrhosis.
6. Extensive surgery, especially on the liver.
7. Severe burn.
8. Extensive trauma.
9. After the blood transfusion reaction.

Definition of  Disseminated Intravascular Coagulopathy (DIC):

1. DIC is an acquired coagulation abnormality where excessive activation of the coagulation factors will show widespread fibrin thrombi in the microcirculation. This process will lead to the following:
   1. Depletion of the coagulation factors.
   2. Decreased count of platelets.
   3. Activation of the thrombin.
   4. Thrombosis of small and midsized-sized blood vessels.
2. Another definition:
3. DIC is uncontrolled activation of the clotting mechanism (factors) that will lead to:
   1. Widespread thrombi formation.
   2. Depletion of coagulation factors.
   3. Decreased platelets count.
   4. Massive hemorrhage.
4. More than one mechanism is often present.

Pathophysiology of Disseminated Intravascular Coagulopathy (DIC)

1. In DIC, there is inappropriate activation of the clotting system.
2. This will lead to systemic or localized fibrin clot formation.
3. Due to increased clotting, there is sludging and excessive bleeding because of the consumption of platelets + clotting factors.
   1. There is increased coagulation which overcomes the inhibitory mechanism.
   2. This will lead to thrombus formation at the site and microcirculation, leading to the hemorrhagic syndrome.
   3. This hemorrhagic syndrome is called DIC, defibrination syndrome, or consumptive coagulopathy.

Definition of  Disseminated Intravascular Coagulopathy (DIC) and  pathogenesis

Disseminated Intravascular Coagulopathy (DIC) mechanism

4. The fibrinolytic system is activated and breaks the clots + fibrin.
5. Fibrinolysis leads to FDP (Fibrin degradation products).
6. FDPs increase bleeding tendency.

Fibrinogenolysis

1. This may be primary or secondary.
2. Primary fibrinogenolysis are rare, and the target is only fibrinogen.
3. Secondary fibrinogenolysis is common. It attacks fibrin but also attacks fibrinogen.

Fibrinogenolysis can be diagnosed by:

1. The platelet count is usually normal.
2. Fibrinogen level is decreased.
3. The potassium sulfate test is negative, which is positive in DIC.
4. Latex test for fibrinogen degradation products (FDP) titer. FDP very markedly increased.
5. Euglobulin clot lysis time (minutes) is decreased.
6. Factor V is decreased.
7. Factor VIII is normal to moderately decreased.

Disseminated Intravascular Coagulopathy (DIC) mechanism

8. Intravascular clots lead to microvascular occlusion leads to injury to the organs.
9. There may be hemolysis of RBCs by passing through these vessels.

Disseminated Intravascular Coagulopathy (DIC) complications

Disseminated Intravascular Coagulopathy (DIC) classification:

1. Acute DIC (Acute hemorrhagic DIC).
2. Chronic DIC (Subacute chronic DIC).

Table: The difference between acute and Chronic DIC:

Disseminated Intravascular Coagulopathy (DIC), Lab diagnosis:

1. The lab. Findings of the DIC reflect direct or indirect excess of thrombin and plasmin generation.
2. No single test is diagnostic.
3. Indirect tests are the lake for thrombin action, including PT, APTT, and thrombin/reptilase clotting tests.
4. The confirmatory test is the demonstration of the fibrin deposition in the biopsy blood vessels which are involved.
5. The following tests are advised to diagnose DIC:
   1. Platelet count. There is thrombocytopenia.
      1. There is an increased plasma level of platelets-specific protein (β-thromboglobulin).
      2. Platelet factor 4.
   2. Prothrombin time (PT).
   3. Partial thromboplastin time (PTT).
   4. Coagulation factor assay.
   5. Fibrinogen degradation products (FDP).
   6. Fibrinogen.
   7. D-dimer.
   8. Prothrombin fragments.
   9. The peripheral blood smear shows schistocytes.
6. Immediately perform the following test that will diagnose the DIC.
   1. PT.
   2. PTT.
   3. Platelet count.
   4. Bleeding time.

Causes of  Disseminated Intravascular Coagulopathy (DIC):

1. These can be summarized into various groups:
   1. Infections.
   2. Trauma with extensive tissue damage.
   3. Vascular abnormalities.
   4. Connective tissue diseases.
   5. Due to toxins like snake bites etc.
   6. Pregnancy and obstetrical complications.
   7. Damage to platelets or RBCs.
   8. Metastatic neoplasm.
2. Broadly DIC can be caused by:
   1. Bacterial Septicemia.
   2. Retention of a dead fetus.
   3. Amniotic fluid embolism.
   4. Liver diseases.
   5. Malignant diseases.
   6. Extensive surgery on the liver or prostate.
   7. Heart bypass surgery.
   8. Extensive trauma.
   9. Severe burns.
   10. Transfusion reaction.

Clinical conditions associated with Disseminated Intravascular Coagulopathy (DIC):

1. Due to Thromboplastin release – Factor VII activation:
   1. Placental abruption.
   2. Sepsis.
   3. Promyelocytic leukemia.
   4. Retained dead fetus syndrome.
   5. Amniotic fluid embolus.
   6. Cardiopulmonary bypass surgery.
   7. Acute intravascular hemolysis.
   8. Adenocarcinoma (mucin-producing).
   9. Trauma.
2. Due to Factor X/II activation:

1. 1. Acute pancreatitis.
   2. Snake venom.
   3. Fat emboli syndrome.
   4. Liver diseases.
2. Due to endothelial cells damage –  Factor XII activation:
   1. Liver diseases.
   2. Intravascular hemolysis.
   3. Immune complex diseases.
   4. Vasculitis.
   5. Burns.
   6. Anoxia.
   7. Acidosis.
   8. Heatstroke.

 Table:  Shows the findings of the various test in DIC:

Laboratory diagnosis of Acute DIC:

Treatment of Disseminated Intravascular Coagulopathy (DIC)

Treatment is two folds:

1. Removal of the underlying pathologic cause.
2. Maintain the blood volume and hemostatic function.
   1. There is a transfusion of the packed red blood cells.
   2. Give fresh frozen plasma.
   3. Give platelets concentrate.
   4. Replace missing blood coagulation factors (components).
3. The main aim of the DIC treatment is the balancing function to restore the body’s ability to coagulate normally.

Questions and answers: