Consumption Coagulopathy Workup

Updated: Oct 08, 2020
  • Author: Himal M Shah, MBBS, MD, DM; Chief Editor: Vikramjit S Kanwar, MBBS, MBA, MRCP(UK)  more...
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Workup

Laboratory Studies

Screening

No single test or combination of tests is adequate to diagnose disseminated intravascular coagulation (DIC). [3] Perform screening tests in all patients, such as platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, and assessment of fibrin degradation products or soluble fibrin monomers. Additional tests that may be useful in aiding in the diagnosis include measurements of antithrombin III, protein C, protein S, D-dimer, fibrinogen, specific coagulation factors such as factor V and VIII, and plasminogen activator inhibitor type I (PAI-1). Clinical judgment in conjunction with these tests provides a means of working towards a diagnosis of DIC, although no single test result alone is confirmatory. [19]

Thrombocytopenia is an almost universal finding, and the complete blood count (CBC) with smear review may reveal findings suggestive of DIC, such as increased platelet size, schistocytes (see the image below), and helmet cells.

Peripheral blood of a child with disseminated intr Peripheral blood of a child with disseminated intravascular coagulation demonstrates thrombocytopenia and many schistocytes (Wright stain, original magnification X 1000).

The PT and the aPTT are usually prolonged on screening tests but may be normal in an individual in the early phase of DIC ("nonovert DIC").

Levels of fibrin or fibrinogen degradation products and D-dimers are usually elevated because of the rapid generation of fibrin and breakdown of cross-linked fibrin polymers. Although sensitive, these tests are not specific.

Fibrinogen levels are often decreased, as is antithrombin III.

The International Society on Thrombosis and Hemostasis (ISTH) DIC scoring system can assist with diagnosis. [20] In the presence of an underlying cause, key tests are performed, and the results are scored as shown in the Table below.

Table. DIC Scoring System (Open Table in a new window)

Measure

Score

0

1

2

3

Platelet count

>100 X 109/L

< 100 X 109/L

< 50 X 109/L

NA

PT prolongation, s

0-3

3-6

6

NA

Fibrinogen level (mg/dL)

>100

< 100

NA

NA

Fibrin split products

NA

NA

+(moderate increase,< 5 X of normal limits)

+++(strong increase,>5X of normal limits)

In pediatric patients with acute promyelocytic leukemia, a score of 6 or greater is associated with a significant risk of hemorrhage. [21] The most important prognostic factor remains the ability to correct the underlying cause and arrest the ongoing derangement of the coagulation system.

Apart from ISTH criteria are similar diagnostic criteria from the Japanese Ministry of Health, Labour and Welfare (JMHLW) and the Japanese Association for Acute Medicine (JAAM).

All criteria have their respective advantages and drawbacks. The sensitivity of the ISTH criteria is poor. The JAAM criteria cannot be applied to all underlying diseases, and the JMHLW criteria have poor sensitivity in cases of infection. [22]

The JMHLW criteria numerically categorize the extent of fibrin degradation product and include underlying disease and clinical symptoms as part of the overall scoring system, whereas underlying disease is an essential component in the ISTH system. [23] The ISTH system is useful for predicting overt DIC.

The ISTH DIC scoring system does not precisely define the extent of the increase in fibrin split products or which marker is being measured. Specifying these fibrin products as either D-dimers or soluble fibrin monomers and clearly defining numerical parameters of these products within the scoring system makes the score a more powerful prognostic indicator. [24, 25]

In a retrospective study evaluating prognostic factors influencing mortality in pediatric patients with DIC, multiorgan dysfunction syndrome, acute respiratory distress syndrome, and cardiovascular and respiratory system dysfunction were associated with increased mortality. [13]

A scoring system used in the pediatric intensive care unit (ICU) at Texas Children's Hospital uses sequential measurement of the same laboratory values along with the clinical condition of the patient to determine whether overt DIC is present. This scoring system has proven to be more sensitive than the ISTH system. [26]

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Other Tests

Because DIC is not the primary disease but a manifestation of underlying illness, diagnosis of the initiating disorder is crucial.

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