Disseminated Intravascular Coagulation - DIC

  • Diagnosis
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Patient with risk factors for DIC in conjunction with bleeding or thrombocytopenia
  • Underlying disorder with known DIC association

Criteria for Diagnosis

  • Score global coagulation test results based on the following scoring system proposed by the International Society on Thrombosis and Hemostasis (ISTH)
    • Platelet count (x109/L)
      • (>100 = 0, 50-100 = 1, <50 = 2)
    • PT prolongation (seconds)
      • (<3 = 0, >3 but <6 = 1, ≥6 = 2)
    • Fibrinogen (g/L)
      • (>1 = 0, <1 = 1)
    • Fibrin-related markers (increase)
      • No increase = 0; moderate increase = 2; strong increase = 3
      • Cutoffs for scoring fibrin-related markers must be established for the specific assay
    • TOTAL
      • If ≥5, compatible with overt DIC – repeat scoring daily
      • If <5, suggestive of non-overt DIC – repeat scoring after 1-2 days

Laboratory Testing

  • CBC –  thrombocytopenia usually present (may be normal in early DIC)
  • Clotting times
    • Prothrombin time (PT) – prolonged (may be normal in early or chronic DIC)
    • Partial thromboplastin time (PTT) – prolonged (may be normal in early or chronic DIC)
    • Thrombin time (TT) – may be increased due to consumption of fibrinogen
  • Fibrin-related marker
    • D-dimer – increased in acute and chronic DIC (best single test)
      • Largely replaced fibrin degradation products (FDP) as a marker of coagulation
      • D-dimer measurements alone have excellent negative predictive value for DIC
      • Normal d-dimer essentially rules out DIC
      • Elevated d-dimer levels are seen in a number of conditions in addition to DIC (eg, pregnancy, acute thrombosis)
  • Coagulation factors
    • Fibrinogen – decreased

Differential Diagnosis

Disseminated intravascular coagulation (DIC) is a disorder characterized by massive systemic activation of coagulation with consumption of platelets and coagulation proteins.

Epidemiology

  • Incidence – >18,000 cases annually in U.S.

Risk Factors

  • Sepsis (bacterial, viral, fungal)
  • Trauma (polytrauma, fat embolism, burns)
  • Malignancy (solid tumors, acute leukemia)
  • Obstetric complications (abruptio placentae, placenta previa, amniotic fluid embolus)
  • Toxic reactions (eg, venomous snake bite)
  • Immunologic reactions (hemolytic transfusion reaction, transplant rejection)
  • Organ destruction (pancreatitishepatic failure)
  • Massive blood loss

Pathophysiology

  • Activation of coagulation pathways
    • Generation of thrombin and formation of fibrin in circulating blood
    • Consumption of coagulation factors and platelets
  • Activation of inflammatory pathways via cytokines
  • Suppression of physiologic anticoagulant pathways
  • Activation and/or impairment of fibrinolysis

Clinical Presentation

  • Generally occurs in the setting of a risk factor listed above
  • Hemorrhage – petechiae, purpura, epistaxis, mucous membrane bleeding
  • Thrombosis – may lead to organ failure
  • Chronic DIC – occurs in cancer patients
    • Thrombosis is primary symptom
    • Referred to as Trousseau syndrome

Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

CBC with Platelet Count 0040002
Method: Automated Cell Count

Limitations

Normal result does not rule out DIC

Prothrombin Time 0030215
Method: Electromagnetic Mechanical Clot Detection

Limitations

Normal result does not rule out DIC

Partial Thromboplastin Time 0030235
Method: Electromagnetic Mechanical Clot Detection

Limitations

Normal result does not rule out DIC

Thrombin Time with Reflex to Thrombin Time 1:1 Mix 0030260
Method: Electromagnetic Mechanical Clot Detection

Limitations

Normal result does not rule out DIC

Fibrinogen 0030130
Method: Electromagnetic Mechanical Clot Detection

Limitations

Normal result does not rule out DIC

D-Dimer 0030057
Method: Immunoturbidimetry

Limitations

Presence of rheumatoid factor, pregnancy, acute thrombosis may lead to false-positive results

Related Tests

Guidelines

Di Nisio M, Baudo F, Cosmi B, D'Angelo A, De Gasperi A, Malato A, Schiavoni M, Squizzato A, Italian Society for Thrombosis and Haemostasis. Diagnosis and treatment of disseminated intravascular coagulation: guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res. 2012; 129(5): e177-84. PubMed

General References

Cauchie P, Cauchie C, Boudjeltia Z, Carlier E, Deschepper N, Govaerts D, Migaud-Fressart M, Woodhams B, Brohée D. Diagnosis and prognosis of overt disseminated intravascular coagulation in a general hospital -- meaning of the ISTH score system, fibrin monomers, and lipoprotein-C-reactive protein complex formation. Am J Hematol. 2006; 81(6): 414-9. PubMed

Franchini M, Lippi G, Manzato F. Recent acquisitions in the pathophysiology, diagnosis and treatment of disseminated intravascular coagulation. Thromb J. 2006; 4(4): 1-9. PubMed

Levi M. Diagnosis and treatment of disseminated intravascular coagulation. Int J Lab Hematol. 2014; 36(3): 228-36. PubMed

Levi M. Disseminated intravascular coagulation. Crit Care Med. 2007; 35(9): 2191-5. PubMed

Toh C, Downey C. Back to the future: testing in disseminated intravascular coagulation. Blood Coagul Fibrinolysis. 2005; 16(8): 535-42. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Lehman CM, Wilson LW, Rodgers GM. Analytic validation and clinical evaluation of the STA LIATEST immunoturbidimetric D-dimer assay for the diagnosis of disseminated intravascular coagulation. Am J Clin Pathol. 2004; 122(2): 178-84. PubMed

Ness P, Creer M, Rodgers GM, Naoum JJ, Renkens K, Voils SA, Alexander A, Recognition, Evaluation and Treatment of Acquired Coagulopathy Consensus (RETACC) Panel. Building an immune-mediated coagulopathy consensus: early recognition and evaluation to enhance post-surgical patient safety. Patient Saf Surg. 2009; 3(1): 8. PubMed

Medical Reviewers

Last Update: February 2016