P1: RLJ/OZN P2: KUF
0521779407-D-01 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:41
Disseminated Intravascular Coagulation 493■Asymptomatic individuals need not be treated.
■Bleeding patients should be treated with as appropriate:
➣Fresh frozen plasma provides all coagulation factors – use for
elevated PT/PTT.
➣Cryoprecipitate provides a concentrated source of fibrinogen –
strongly consider its use when fibrinogen level falls below 100
mg/dL – such low levels are not uncommon in amniotic fluid
embolism, and repletion of fibrinogen may go far toward nor-
malizing the PT/PTT.
➣Platelets should be transfused judiciously – in patients with
major bleeding try to keep >50,000/mm3, for minor bleeding
>20,000/mm3
➣Use of heparin is not routinely indicated. Consider in patients
with DIC and thrombosis: dose at 500-1500 U/hr without regard
to PTT.
■For overt DIC in sepsis, consider treatment with recombinant human
activated protein C (drotrecogin alfa, activated) or treatment with
antithrombin without heparin – either of these may reduce mortality.
➣Overt DIC is defined as a combination of thrombocytopenia, ele-
vated D-dimer, increased PT, and decreased fibrinogen, though
all need not be present.HUS in a Child with a History of a Diarrheal Illness
■HUS occurring as part of a diarrheal illness is usually self-limited.
Supportive care only is indicated.TTP/HUS
■Once the diagnosis is established:
➣Discontinue any offending agents (i.e., clopidogrel, cyclosporin).
➣Plasma exchange is the treatment of choice – usually performed
daily with one plasma volume exchanged with FFP until the
platelet count and LDH have been in the normal range for a
few days. Alternatively, FFP infusion may be used.
➣TTP/HUS that does not respond to one volume plasma exchange
may respond to larger volume exchange – alternatively, cryo-poor
plasma may be of utility.
■Routine use of corticosteroids is not indicated and may increase the
risk of infectious complications.
■Renal failure may require dialysis.
■Splenectomy or treatment with rituximab may be considered in
relapsing TTP.