Abstract
Disseminated intravascular coagulation (DIC) is categorized into bleeding, organ failure, massive bleeding, and non-symptomatic types according to the sum of vectors for hypercoagulation and hyperfibrinolysis. The British Committee for Standards in Haematology, Japanese Society of Thrombosis and Hemostasis, and the Italian Society for Thrombosis and Haemostasis published separate guidelines for DIC; however, there are several differences between these three sets of guidelines. Therefore, the International Society of Thrombosis and Haemostasis (ISTH) recently harmonized these differences and published the guidance of diagnosis and treatment for DIC. There are three different diagnostic criteria according to the Japanese Ministry Health, Labour and Welfare, ISTH, and Japanese Association of Acute Medicine. The first and second criteria can be used to diagnose the bleeding or massive bleeding types of DIC, while the third criteria cover organ failure and the massive bleeding type of DIC. Treatment of underlying conditions is recommended in three types of DIC, with the exception of massive bleeding. Blood transfusions are recommended in patients with the bleeding and massive bleeding types of DIC. Meanwhile, treatment with heparin is recommended in those with the non-symptomatic type of DIC. The administration of synthetic protease inhibitors and antifibrinolytic therapy is recommended in patients with the bleeding and massive bleeding types of DIC. Furthermore, the administration of natural protease inhibitors is recommended in patients with the organ failure type of DIC, while antifibrinolytic treatment is not. The diagnosis and treatment of DIC should be carried out in accordance with the type of DIC.
Highlights
Disseminated intravascular coagulation (DIC) is a syndrome characterized by the systemic activation of blood coagulation, which generates intravascular thrombin and fibrin, resulting in the thrombosis of small- to mediumsized vessels and organ dysfunction and severe bleeding [1,2]
A prospective study in Japan reported no significant differences in the odds ratio for predicting DIC outcomes among these three diagnostic criteria [20], suggesting that the identification of molecular hemostatic markers and changes of global coagulation tests is required in addition to the application of scoring systems
The administration of heparin is not recommended in patients with bleeding or massive bleeding type of DIC due to the increased risk of bleeding, it is recommended in those with the nonsymptomatic type of DIC in order to prevent the onset of deep vein thrombosis (DVT) (Table 3)
Summary
Disseminated intravascular coagulation (DIC) is a syndrome characterized by the systemic activation of blood coagulation, which generates intravascular thrombin and fibrin, resulting in the thrombosis of small- to mediumsized vessels and organ dysfunction and severe bleeding [1,2]. Heparin the administration of anticoagulant treatment is a rational approach based on the notion that DIC is characterized by extensive activation of coagulation, there are several differences in the recommendations for the use of heparin in DIC patients between the four guidelines (Table 1) [3,4,5,6]. Gabexate mesilate® and nafamostat® have been frequently used and evaluated in Japan [13,52,53]; there are no RCTs showing any reductions in mortality or improvements in the rate of resolution of DIC As these drugs have mild anticoagulant and antifibrinolytic effects, they are often used in patients with the bleeding, massive bleeding, and non-symptomatic types of DIC (Table 3). Antifibrinolytic treatment Antifibrinolytic agents are effective in treating bleeding, the use of these drugs in patients with the organ failure or non-symptomatic type of DIC is generally not recommended [58]. The administration of antifibrinolytic agents in these cases must occur in the early period of management before the levels of PAI-1 and other endogenous antifibrinolytics become elevated
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