The Fellow on Call: The Heme/Onc Podcast

Episode 016: Heme/Onc Emergencies, Pt. 5: DIC and Intro to TMAs

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May 25, 2022

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ANECDOTE

Case: Severely Ill Patient

A 61-year-old man presented with fever, altered mental status, and very low platelets after eating questionable beef.
His labs showed neutrophilic leukocytosis, anemia, acute kidney injury, and coagulopathy suggesting a critical illness.

ADVICE

Consider TMAs in Differential

Always consider thrombotic microangiopathies like TTP and HUS in patients with fever, AKI, anemia, and thrombocytopenia.
These cause microvascular clots leading to RBC shear stress and end-organ damage and must be ruled out promptly.

ADVICE

Use Peripheral Smear for Diagnosis

Review the peripheral blood smear for schistocytes when thrombocytopenia and critical illness are present.
Presence of schistocytes can support diagnoses like DIC or thrombotic microangiopathies but quantity also matters.

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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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