Disseminated intravascular coagulation
Stem
A 68-year-old man, 80 kg, is in the operating room for a Hartmann procedure for perforated diverticulitis with fecal peritonitis. He is on norepinephrine. After the colon is out, the surgeon reports diffuse oozing from every raw surface, and blood is seeping around the arterial line. Labs: platelets 42 × 10⁹/L, prothrombin time 7 seconds above normal, fibrinogen 0.9 g/L, and a markedly raised D-dimer.
Question
What is causing the bleeding, and how will you manage it?
Ideal answer
HeadlineOvert sepsis-driven DIC, ISTH score 8 of 8, where 5 or more is compatible.1 Source control first; I replace what he bleeds from meanwhile.
- Back fast source control; antibiotics and norepinephrine continue, because treating the cause is the cornerstone.2
- Platelets, because he is bleeding with a count under 50.2
- Fresh frozen plasma 15 mL/kg, 1200 mL, accepting that 30 mL/kg corrects more fully if volume allows.2
- Cryoprecipitate or fibrinogen concentrate, because fibrinogen is below 1 g/L; two pools give about 3 g, raising it roughly 1 g/L.2
- Warm, normal ionized calcium and pH, no antifibrinolytics, which are not recommended in DIC unless hyperfibrinolysis dominates.2
Watch for: platelets, PT and fibrinogen after each round, plus viscoelastic testing if available, because DIC changes by the hour.2
Breaking down the answer
- The score — ISTH: platelets (above 100 = 0, 100 or less = 1, 50 or less = 2), fibrin markers (0, 2 or 3), PT prolongation (under 3 s = 0, 3–6 s = 1, 6 s or more = 2), fibrinogen (1 g/L or less = 1).1
- Treat the cause — DIC is a process, not a disease; products only buy time until the source is controlled.2
- Transfuse for bleeding, not numbers — prophylactic platelets are avoided unless bleeding risk is high.2
- Plasma alternative — if volume overload limits plasma, prothrombin complex concentrate partially corrects the defect.2
- Why no tranexamic acid — it is reserved for DIC with primary hyperfibrinolysis and severe bleeding;2 saying why shows I understand the mechanism.
- Lethal triad — hypothermia and acidosis worsen any coagulopathy in an open abdomen.
Follow-up question
The bleeding settles with source control and products. Six hours later in the ICU, his fingers and toes turn dusky and cold despite a stable blood pressure, and he has a new skin rash of purpura. What is happening and what do you do?
Follow-up answer
HeadlineThrombosis-predominant DIC with microvascular clotting threatening his digits, possibly purpura fulminans. I tell ICU and the surgeon the balance has swung to clotting.
I examine the limbs, document pulses and perfusion, and review the vasopressor dose, since high norepinephrine also causes digital ischemia. With bleeding controlled, therapeutic heparin should be considered, and every critically ill, non-bleeding patient with DIC should receive prophylactic heparin or low-molecular-weight heparin.2 I keep treating the sepsis and repeat the coagulation tests and the score daily.1
Pitfalls that cost points
- Treating laboratory numbers in a patient who is not bleeding.
- Using the ISTH score to rule out DIC in pregnancy, where it is insensitive.3
Rapid-fire
Q: What score indicates overt DIC? A: An ISTH score of 5 or more; below 5, repeat it over the next one to two days.1
Q: Which settings use the ISTH score? A: Adults and children, especially in sepsis and critical illness; it tracks severity and mortality.3
Q: When is heparin used in DIC? A: Therapeutic doses when thrombosis predominates.2
Q: What can you give if plasma volume is a problem? A: Prothrombin complex concentrate, which corrects only part of the defect.2
Numbers to know
| Item | Value |
|---|---|
| ISTH overt DIC | Score 5 or more1 |
| Platelets in bleeding | Transfuse below 50 × 10⁹/L2 |
| Plasma | 15 mL/kg initial; 30 mL/kg more complete2 |
| Fibrinogen | Replace below 1 g/L2 |
| Two cryoprecipitate pools | About 3 g, raises fibrinogen ~1 g/L2 |
Links
- Sepsis and septic shock, Massive hemorrhage and transfusion, Perioperative hypothermia and coagulopathy, Obstetric hemorrhage: previa, accreta, atony, Amniotic fluid embolism
- BCSH guideline on DIC (2009); ISTH overt DIC score (2001)
Sources
- 1.How to diagnose disseminated intravascular coagulation (ISTH overt DIC score) · Stago · webit.stago.comReproduces Table II of Taylor et al., Thromb Haemost 2001 (ISTH).
- 2.Guidelines for the diagnosis and management of disseminated intravascular coagulation · British Committee for Standards in Haematology (Br J Haematol), 2009 · confluence.cornell.eduLevi M, Toh CH, Thachil J, Watson HG.
- 3.ISTH DIC score · The Blood Project, 2025 · thebloodproject.comAird W; notes poor sensitivity in pregnancy.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.