ICU · Haematology / coagulation
Disseminated Intravascular Coagulation (DIC) — Bleeding AND Thrombosis
Also known as DIC · Disseminated intravascular coagulation · Consumptive coagulopathy · Defibrination syndrome · ISTH DIC score · Purpura fulminans · Thrombohaemorrhagic disorder · D-dimer · Schistocytes · Microangiopathic haemolytic anaemia
DIC — the 2025 ISTH definition (an acquired, life-threatening intravascular disorder of systemic coagulation activation, dysregulated fibrinolysis and endothelial injury, resulting in microthrombosis), its thrombotic and haemorrhagic phenotypes, the 2025 overt-DIC score and sepsis-induced coagulopathy (SIC), management by guideline (treat the cause; transfuse for bleeding; heparin when thrombosis predominates; antifibrinolytics only in hyperfibrinolytic bleeding), the failed anticoagulant trials (KyberSept, OPTIMIST, PROWESS-SHOCK, SCARLET), APL coagulopathy (ELN) and purpura fulminans.
Checked against its sources on 8 Oct 2026
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- Treatment of the underlying condition is the cornerstone of DIC therapy
- Transfuse platelets or plasma for bleeding (or before an invasive procedure), not on laboratory results alone
- Therapeutic heparin only where thrombosis predominates (thromboembolism, purpura fulminans with acral ischaemia)
- In general no antifibrinolytics — the exception is severe bleeding with a hyperfibrinolytic state (leukaemia, trauma)
- Suspected APL is a medical emergency — start ATRA immediately on suspicion and replace fibrinogen and platelets
Meet the patient
A 62-year-old man reaches the unit in septic shock from a pneumonia — purpura across his shins, blood oozing from cannula sites, a platelet count that has fallen from 288 to 42 overnight, fibrinogen 0.9 g/L and a D-dimer far above the upper normal limit. He is bleeding from puncture sites while his kidneys fail — the two faces of DIC at once.[1]
The two questions that decide his next hour: what is the underlying condition? (treating it is the cornerstone) and is this thrombotic or haemorrhagic DIC? (it decides between heparin and products).[3][1]
References16ShowHide
- [1]Iba T, Levy JH, Maier CL, et al. Updated definition and scoring of disseminated intravascular coagulation in 2025: communication from the ISTH SSC Subcommittee on Disseminated Intravascular Coagulation. Journal of thrombosis and haemostasis : JTH, 2025.PMID 40216223
- [2]Bakhtiari K, Meijers JC, de Jonge E, et al. Prospective validation of the International Society of Thrombosis and Haemostasis scoring system for disseminated intravascular coagulation. Critical care medicine, 2004.PMID 15599145
- [3]Wada H, Thachil J, Di Nisio M, et al. Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines. Journal of thrombosis and haemostasis : JTH, 2013.PMID 23379279
- [4]Levi M, Toh CH, Thachil J, et al. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. British journal of haematology, 2009.PMID 19222477
- [5]Adelborg K, Larsen JB, Hvas AM Disseminated intravascular coagulation: epidemiology, biomarkers, and management. British journal of haematology, 2021.PMID 33555051
- [6]Levy JH, Welsby I, Goodnough LT Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion, 2014.PMID 24117955
- [7]Rubin RN, Colman RW Disseminated intravascular coagulation. Approach to treatment. Drugs, 1992.PMID 1282866
- [8]Warren BL, Eid A, Singer P, et al. Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial. JAMA, 2001.PMID 11597289
- [9]Abraham E, Reinhart K, Opal S, et al. Efficacy and safety of tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis: a randomized controlled trial. JAMA, 2003.PMID 12851279
- [10]Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. The New England journal of medicine, 2012.PMID 22616830
- [11]Vincent JL, Francois B, Zabolotskikh I, et al. Effect of a Recombinant Human Soluble Thrombomodulin on Mortality in Patients With Sepsis-Associated Coagulopathy: The SCARLET Randomized Clinical Trial. JAMA, 2019.PMID 31104069
- [12]Sanz MA, Fenaux P, Tallman MS, et al. Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNet. Blood, 2019.PMID 30803991
- [13]Smith OP, White B, Vaughan D, et al. Use of protein-C concentrate, heparin, and haemodiafiltration in meningococcus-induced purpura fulminans. Lancet (London, England), 1997.PMID 9393338
- [14]Rintala E, Kauppila M, Seppälä OP, et al. Protein C substitution in sepsis-associated purpura fulminans. Critical care medicine, 2000.PMID 10921567
- [15]Iba T, Nisio MD, Levy JH, et al. New criteria for sepsis-induced coagulopathy (SIC) following the revised sepsis definition: a retrospective analysis of a nationwide survey. BMJ open, 2017.PMID 28963294
- [16]Nwagha TU, Hajjaj OI, Levy JH, et al. Global practice and challenges in the diagnosis and management of disseminated intravascular coagulation: communication from the ISTH SSC Subcommittee on Disseminated Intravascular Coagulation. Journal of thrombosis and haemostasis : JTH, 2026.PMID 41655787