Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our second hematologic emergency: disseminated intravascular coagulation (DIC) with an added bonus of an intro to thrombotic microangiopathic anemias (TMAs).
Be sure to check out episode 009 on thrombocytopenia for a general approach and differential!
Disseminated intravascular coagulation (DIC):
Workup:
CBC
CMP
PT, PTT, INR
Fibrinogen
Peripheral smear - concern for schistocytes. Example of these cells from ASH image bank: https://imagebank.hematology.org/image/60306/schistocytes?type=upload#:~:text=A%20schistocyte%20is%20present%20in,angles%20and%2For%20straight%20borders.
Basic mechanism of DIC is consumption of clotting factors leading to coagulopathy
Need to be weary of thrombotic microangiopathy: Small blood clots forming in the small vessels leading to endothelial damage, which cause shear stress on the RBCs, which then break down into a schistocyte (AKA triangulocyte or helmet cell)
Examples: thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS)
Management (our opinion!):
- Repeat coags q4-6 hours initially (but base interval based on patient) NOTE: INR Is NOT a good assessment of “clotting status” in these situations
- Repeat fibrinogen q4-6 hours initially (but base interval based on patient); keep fibrinogen >100 with cryoprecipitate in more stable patients; consider higher thresholds for more acutely ill patients (such as >150)
- Repeat CBC q6-8 hours initially; can provide platelets if low, especially if they are bleeding
- Workup and treatment for trigger of DIC (infection, trauma, medications, etc.)
How does cirrhosis affect data interpretation?
- Use clinical context to determine if labs are acutely abnormal or if they have signs/symptoms to suggest underlying liver dysfunction
- In the acute setting, always just replace what is missing!
How can you tell the difference between nutritional deficiencies vs. consumption (as in with DIC?)
- Factor activity levels! Consider checking: Factor 8 (made in endothelium), Factor 5 (Vit K independent), Factor 7 (vitamin K dependent)
- If all down, then consider DIC
- If Vit K-dependent low, then nutritional deficiency
Reference:
https://ashpublications.org/blood/article/131/8/845/104418/How-I-treat-disseminated-intravascular-coagulation - Great How I Treat article from Blood
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