Haematology and Coagulation in the ICU

Also known as DIC · Thrombocytopenia · Coagulopathy · VTE prophylaxis · Massive transfusion · Thromboelastography · Anticoagulation reversal

Haematology and coagulation in the ICU: waterfall versus cell-based models, sepsis-induced coagulopathy and the SIC score, harmonised DIC management, HIT and the 4Ts, TTP with plasma exchange and caplacizumab, PROTECT thromboprophylaxis, major haemorrhage (CRASH-2 timing, PROPPR, fibrinogen, platelet and calcium targets, ITACTIC) and reversal with 4F-PCC, idarucizumab and andexanet.

medium22 referencesUpdated 8 Oct 20267 min readSource-verified · Oct 2026

Checked against its sources on 8 Oct 2026

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8 MCQs

Why coagulation dominates ICU haematology

Severe sepsis is almost invariably associated with systemic activation of coagulation, and the cross-talk between haemostasis and inflammation probably contributes to organ dysfunction.^[4] Coagulation augments inflammation — thrombin, factor Xa and the tissue factor-factor VIIa complex act on protease-activated receptors — and the natural anticoagulants can limit that response.^[3] At the other end, the bleeding patient needs rapid, protocolised replacement of fibrinogen, platelets and plasma, early tranexamic acid, and reversal of any anticoagulant.^[13]

References22Show

[1]DAVIE EW, RATNOFF OD WATERFALL SEQUENCE FOR INTRINSIC BLOOD CLOTTING. Science (New York, N.Y.), 1964.PMID 14173416
[2]Hoffman M, Monroe DM 3rd A cell-based model of hemostasis. Thrombosis and haemostasis, 2001.PMID 11434702
[3]Esmon CT Role of coagulation inhibitors in inflammation. Thrombosis and haemostasis, 2001.PMID 11487041
[4]Levi M, van der Poll T Coagulation and sepsis. Thrombosis research, 2017.PMID 27886531
[5]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
[6]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
[7]Cuker A Clinical and laboratory diagnosis of heparin-induced thrombocytopenia: an integrated approach. Seminars in thrombosis and hemostasis, 2014.PMID 24363239
[8]Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. Journal of thrombosis and haemostasis : JTH, 2006.PMID 16634744
[9]Rock GA, Shumak KH, Buskard NA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis Study Group. The New England journal of medicine, 1991.PMID 2062330
[10]Scully M, Cataland SR, Peyvandi F, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. The New England journal of medicine, 2019.PMID 30625070
[11]Knoebl P, Cataland S, Peyvandi F, et al. Efficacy and safety of open-label caplacizumab in patients with exacerbations of acquired thrombotic thrombocytopenic purpura in the HERCULES study. Journal of thrombosis and haemostasis : JTH, 2020.PMID 31691462
[12]PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Cook D, Meade M, et al. Dalteparin versus unfractionated heparin in critically ill patients. The New England journal of medicine, 2011.PMID 21417952
[13]Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical care (London, England), 2019.PMID 30917843
[14]CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet (London, England), 2010.PMID 20554319
[15]CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet (London, England), 2011.PMID 21439633
[16]Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet (London, England), 2018.PMID 29126600
[17]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA, 2015.PMID 25647203
[18]Baksaas-Aasen K, Gall LS, Stensballe J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive care medicine, 2021.PMID 33048195
[19]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
[20]Sarode R, Milling TJ Jr, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation, 2013.PMID 23935011
[21]Pollack CV Jr, Reilly PA, van Ryn J, et al. Idarucizumab for Dabigatran Reversal - Full Cohort Analysis. The New England journal of medicine, 2017.PMID 28693366
[22]Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. The New England journal of medicine, 2019.PMID 30730782