Disseminated Intravascular Coagulation in Paediatrics
Rajagopal et al, Arch Dis Children Abstrac
Disseminated intravascular coagulation (DIC) in paediatrics is associated with significant morbidity and mortality. Although there have been several recent advances in the pathophysiology of DIC, most of these studies were done in adults. Since the haemostatic system is very different in early life and changes dramatically with age, creating a variety of challenges for the clinician, delay in the diagnosis of DIC can happen until overt DIC is evident. In this review article, we report the aetiology, pathophysiology, clinical manifestations, diagnostic tests and a management algorithm to guide paediatricians when treating patients with DIC.
Disseminated intravascular coagulation (DIC) is a serious, acquired clinical condition that is characterised by systemic activation of the haemostatic system resulting in excess thrombin deposition leading to microvascular thrombi. In addition, the consumption of platelets and depletion of plasma clotting factors from ongoing activation of coagulation and the imbalance between the fibrinolytic and antifibrinolytic systems can also induce severe bleeding.[2] This intravascular coagulation can disseminate to the different organs and cause a spectrum of clinical effects. This concept is encapsulated by the International Society of Thrombosis and Haemostasis (ISTH) DIC subcommittee definition of DIC: “an acquired syndrome characterized by intravascular activation of coagulation with loss of localization arising from different causes. It disrupts the microvascular endothelium and leads to multi-organ dysfunction syndrome (MODS) if the process is sufficiently severe”. The presence of concomitant thrombosis and bleeding in DIC complicate the treatment strategies.
Conclusion
DIC in children is associated with high mortality. Clinical manifestations in children and neonates vary and management strategies should be individualised. Early involvement of multidisciplinary teams is crucial to initiate appropriate treatments adequately. In paediatrics, the challenge is in implementing evidence-based diagnostic criteria according to the clinical and laboratory results for each patient. The diagnosis of DIC should not be interpreted based on a single result and careful observation on the patterns of clinical signs and serial results are mandatory. However, difficulty in obtaining blood samples from critically ill children is a major challenge. Treating the underlying condition and supportive treatment with blood components in bleeding patients are the mainstay of treatment. UFH is generally recommended in non-bleeding patients. Administration of other pharmaceutical agents is not routinely recommended, but requires advice from a haematologist in specific situations. Most of the treatment strategies in DIC are extrapolated from adult studies. Hence, further trials are needed to validate the ISTH DIC diagnostic criteria and management approach in paediatrics.