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

What this episode covers

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 Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCall Instagram: @TheFellowOnCall Listen in on: Apple Podcast, Spotify, and Google Podcast