Disseminated Intravascular Coagulation (DIC)

DIC is a consumptive coagulopathy characterised by simultaneous microvascular thrombosis and haemorrhage. The ISTH score ≥5 indicates overt DIC. The single most important step is treating the underlying cause — all haematological support is a bridge.

ISTH DIC Scoring Algorithm

The pathway

1 · Diagnose and score (ISTH)

Platelet count: >100 = 0, 50–100 = 1, <50 = 2
PT prolongation: <3s = 0, 3–6s = 1, >6s = 2
Fibrinogen: >1g/L = 0, <1g/L = 1
D-dimer/FDPs: no increase = 0, moderate increase = 2, strong increase = 3
Score ≥5 = overt DIC; repeat daily if score 4

2 · Treat the underlying cause

Sepsis: cultures + broad-spectrum antibiotics immediately
Obstetric: delivery of placental products
APML: ATRA (all-trans retinoic acid) urgently — reduces DIC-related mortality
Trauma: haemorrhage control, damage-control resuscitation

3 · Correct haemostasis if actively bleeding

FFP 15ml/kg IV to replace clotting factors
Cryoprecipitate (2 pools = 10 units) if fibrinogen <1.5g/L
Platelet transfusion if platelets <50 × 10⁹/L with active bleeding (or <20 if no bleeding)

4 · Fibrinogen replacement

Cryoprecipitate preferred over FFP for fibrinogen replacement
Target fibrinogen >1.5g/L
Fibrinogen concentrate (Riastap) 3–4g IV as alternative if cryoprecipitate unavailable

5 · Tranexamic acid (selective use)

TXA 1g IV over 10 minutes: use in obstetric DIC (PPH)
AVOID TXA in sepsis-related DIC — risk of microvascular thrombosis
AVOID TXA in APML-related DIC

6 · Heparin (selective use only)

AVOID heparin in most DIC
Low-dose LMWH may be considered in predominantly thrombotic DIC (e.g. aortic aneurysm, dead fetus syndrome) after senior haematology review

7 · Monitoring

Repeat FBC, PT/APTT, fibrinogen, D-dimer every 6 hours in active DIC
Monitor urine output (renal microvascular involvement)
Daily review of ISTH score

8 · Escalate and involve haematology

All patients with overt DIC require urgent haematology input
APML-related DIC: haematology + oncology same day
Obstetric DIC: obstetrics + haematology + critical care team

Drugs

Drug	Dose	Route	Notes
Fresh Frozen Plasma (FFP)	15ml/kg	IV	First-line for active bleeding. Replaces all clotting factors. Each unit ~250ml — anticipate volume load.
Cryoprecipitate	2 pools (10 units)	IV	Give if fibrinogen <1.5g/L. Each pool raises fibrinogen by ~0.5g/L.
Tranexamic acid	1g over 10 minutes	IV	Obstetric DIC only. AVOID in sepsis-related or APML-related DIC.
ATRA (tretinoin)	45mg/m²/day in divided doses	PO	APML-related DIC: start urgently. Reduces DIC by inducing differentiation of leukaemic promyelocytes.
Platelet concentrate	1 adult therapeutic dose	IV	If platelets <50 × 10⁹/L with bleeding, or <20 × 10⁹/L prophylactically.

When to escalate

ISTH DIC score ≥5 with active haemorrhage unresponsive to replacement,Fibrinogen <1g/L despite cryoprecipitate transfusion,Suspected APML (blast crisis, DIC in young patient with bleeding) — haematology emergency,Platelet count <20 × 10⁹/L in non-bleeding patient,Oliguria or rising creatinine suggesting renal microvascular involvement,Obstetric DIC with ongoing haemorrhage — activate major haemorrhage protocol

Reference: BSH Guidelines for the Diagnosis and Management of DIC 2009 (updated 2016)

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